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Manor Court Of Princeton

140 North Sixth Street, Princeton, IL 61356 · Non profit - Corporation · 125 certified beds · (815) 875-6600 Medicare & Medicaid certified

Call the home — (815) 875-6600 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0605, F0609, F0610) — most recent Jun 2026Behavioral-health or dementia-care citations — no harm found (F0744, F0758)
Insights

On the public record, this home looks stronger than most — but visit before you decide.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (32% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
535 Park Ave E · (815) 875-4531 · Call to confirm hours
Pharmacy
530 Park Ave E · (309) 672-5682 · Call to confirm hours
Grocery
457 S Main St
Park
2 S Main St · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased25.5%13.4%15.4%worse
Long-stay residents who lose too much weight5.6%6.3%5.4%typical
Long-stay residents with a catheter left in their bladder0.5%0.9%0.9%better
Long-stay residents with a urinary tract infection2.2%1.5%2.0%worse
Long-stay residents with depressive symptoms31.4%54.2%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury6.7%3.1%3.3%worse
Long-stay residents whose ability to walk worsened20.8%14.3%16.1%worse
Long-stay residents on antianxiety or hypnotic medication22.2%18.3%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%91.8%95.3%typical
Long-stay residents with pressure ulcers5.0%4.8%4.7%typical
Long-stay residents with worsening bladder/bowel control14.9%20.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table0.4%21.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.9%2.2%1.4%better
Short-stay residents given the seasonal flu vaccine94.6%63.1%79.4%better
Short-stay residents rehospitalized after admission22.5%26.1%22.6%typical
Short-stay residents with an outpatient ER visit18.5%13.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.322.021.67better
Long-stay outpatient ER visits per 1,000 resident days3.702.221.80worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

49.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 180 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

49.6%U.S. median 51.5%
Got home and stayed home
10.7%U.S. median 10.7%
Went back to hospital
62.0%U.S. median 56.6%
Met the expected recovery
0.37U.S. median 0.31
Therapy hours / resident / day
0.22hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 62.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 121 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.37 therapist hours per resident per day in 2026Q1 — more than 63% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 18% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF49.6%CMS range 44.3–57.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.7%CMS range 7.4–14.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge62.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge45.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge60.3%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge98.8%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.3%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.7%CMS range 4.0–10.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.541.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.71
RN hours/ resident / day
0.56
LPN hours/ resident / day
2.64
Aide hours/ resident / day
3.92
Total nurse hours/ resident / day
0.57
RN hoursweekends
32.5%
Total nursing turnover
23.5%
RN turnover

How full it usually is: this home is certified for 125 beds and averages 103.9 residents a day — about 83% occupied, or roughly 21 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.92 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.71 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.64 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.54 hrs/resident/day on weekends vs 4.07 on weekdays — 13% thinner on weekends. RN hours go from 0.77 to 0.57 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 32% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

7
deficiencies at the latest standard inspection (2025-04-30)
9
at the previous standard inspection (2024-05-30)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.

  • Potential for harm · D2026-06-13 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to investigate an alleged allegation of physical abuse. This applies to 1 of 3 residents (R1) reviewed for physical abuse in the sample of 4. The findings include:On 6/13/26 at 11:10 AM, V8 Certified Nursing Assistant (CNA) stated, she came into work and was receiving report from V6 CNA. V6 CNA told V8 that R1 was acting crazy on her shift and that it was so bad, she had to pin him down. V8 asked V6 what she exactly meant by that. V6 demonstrated to V8 that she grabbed R1 by his hands and was holding him down. V8 reported that to V7 Registered Nurse (RN). On 6/13/26 at 10:49 AM, V7 RN stated, V8 CNA reported to her during CNA to CNA report, V7 reported R1 was wound up that shift and she had to hold him down to keep him in bed. V8 reported that she questioned what that meant and asked V6 CNA to demonstrate what she did. V8 reported to V7 that V6 showed her, she held him down in bed. V7 RN stated, V6 CNA was already gone for the night from her shift. She…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-08 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to notify local police and a resident's physician of an allegation of sexual abuse for one of eight residents (R1) reviewed for abuse.Findings include:The facility's Abuse Prohibition and Reporting policy dated 11/28/19 documents the following under Procedure: Prevention of Abuse; 4. The administration shall immediately contact local law enforcement authorities in the following situations: Sexual abuse by a staff member, another resident, or a visitor. This policy also documents under Abuse or neglect examination and protection: 1. The shift nurse on duty who is first made aware of any alleged abuse or neglect concerning any resident shall immediately examine the resident. and 7. The shift nurse shall call the resident's attending physician.On 1/8/25 at approximately 10:00am, V1 Administrator provided a document titled Regulatory Timeline - Allegation of Abuse. The Timeline documents the following: The facility received a concern involving (R1) on 12/27/25 at 1:15pm. The nurse (V6 RN/Registered Nurse) was approached by (R1's)…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-30 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Observation, Interview and Record Review, the facility failed to document a diagnosis and identify target behaviors to warrant the use of an antipsychotic medication and provide appropriate justification for a failed gradual dose reduction of Risperdal (antipsychotic) for one of one resident (R2) reviewed for antipsychotic medications in the sample of 34. Findings include: The facility's Psychopharmacologic Drug Usage Procedure policy, dated 10/18/17, documents A Psychopharmacologic Drug is any medication used for managing behavior, stabilizing mood, or treating psychiatric disorders. This includes the following types of drugs: antipsychotic, antidepressants, anti-anxiety medications, and sedatives/hypnotics. This policy also documents, Use of psychopharmacological medications requires assessment by the attending physician, and specific orders must be written by the attending physician with supporting diagnosis. Documentation of behaviors and conditions requiring the use of these medications must be…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-30 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to revise a care plan to accurately reflect a resident's wound condition for one of 21 residents (R13) reviewed for care plan accuracy in the sample of 34. Findings include: R13's current medical record documents the following diagnoses: Acute Hematogenous Osteomyelitis of right ankle and foot; Stage IV Pressure Ulcer of right heel; Type 2 Diabetes Mellitus with Diabetic Nephropathy; Type 1 Diabetes Mellitus with other specified complication; and Peripheral Vascular Disease. On 04/28/25 at 01:25 PM, V11 (Registered Nurse) stated R13 was admitted to the facility with a venous stasis wound on her right heel. V11 stated, (R13) recently had a skin graft in place on her right heel. The current physician's orders are to leave her foot dressing in place until she goes back to see the wound doctor. R13's current Care Plan documents the following focuses: (R13) requires Enhanced Barrier Precautions related to presence of diabetic ulcer to right heel; (R13) is at increased risk for pressure ulcers and impaired skin integrity related to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-30 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to address and implement care plan interventions for a resident's ongoing, significant weight loss for one of three residents (R42) reviewed for weight loss in the sample of 34. Findings Include: The Facility's Weight Monitoring Policy dated/revised 09/06/24, documents, To consistently assess for significant weight loss or gain. Licensed staff will notify physician of the following, 7.5% or more gain or loss in a 90-day period, 10% or more gain or loss in a 180-day period, events will be opened for a significant weight loss. Notification to the physician must be documented, and whether or not new orders were received for either significant weight losses or gains. Families/POA (power of attorney) must be notified of significant weight loss or gain. The weight committee will review all residents with significant weight gains or losses and other residents of concern and refer to the RD (registered dietician) as needed. The dietician will review significant weight losses and any other residents referred by the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-30 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to maintain cleanliness of tube feeding equipment for one of one resident (R102) reviewed for tube feeding in a sample of 34. FINDINGS INCLUDE: The facility policy, Tube Feeding dated (revised) 03/03/2022 directs staff, To provide a source of nourishment when oral feedings are neither possible nor desired due to a resident condition. When feeding is completed, assure comfort of resident. Non-disposable equipment is to be wiped down with a damp cloth on a daily basis and PRN (as needed) to maintain cleanliness with the facility approved disinfectant. Personnel Responsible: Licensed Staff. R102's current Physician Order Sheet, dated April 2025 includes the following diagnoses: Cerebral Infarction, Hemiplegia and Hemiparesis and Dysphagia. Also included are the following physician orders: Give Osmolyte (nutritional supplement) 1.2 at 75 ML (Milliliters)/HR (Hour) x 23 hours. Assess for placement of tube prior to administration of feeding via aspirating gastric contents. Once A Day at 8:00 P.M. On 4/28/25 at 10:06…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-30 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure aseptic technique was followed during intravenous medication administration and failed to perform a physician-ordered flush prior to the administration of an intravenous medication for one of one residents (R80) receiving intravenous medications, in a sample of 34. FINDINGS INCLUDE: The facility policy, Pharmaceutical Procedures, dated (revised) 01/05/23 directs staff, All medications shall be given upon the written order of a physician. All such orders shall be given as prescribed by the physician. The facility policy, Infection Control, dated (revised) 12/17/2019 directs staff, All residents with known or suspected infectious conditions shall be cared for using the most appropriate nursing care determined for the benefit and safety of the resident concerned, the other residents in the facility and the safety of the employees. Standard Precautions are based upon the principle that all blood, body fluids, secretions, excretions, non-contact skin and mucous membranes may contain transmissible infectious…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-30 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Interview and Record Review, the facility failed to ensure a resident with a diagnosis of Dementia had a Care Plan to include goals and interventions to manage Dementia, for one of one resident (R2) reviewed for Dementia Care in the sample of 34. Findings include: The facility's Care Plan policy, dated 6/1/22, documents It is the policy of this facility to develop and implement a Base Line Care Plan, a Comprehensive Person-Centered Care Plan and conduct Care Plan meetings as appropriate for each resident, consistent with resident rights, that includes measurable objectives and timeframe to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. This same policy documents The comprehensive care plan will describe, at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. R2's current electronic Face Sheet documents…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-30 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review, the facility failed to document a rationale for the continued use of antibiotic therapy for one of three residents (R69) reviewed for unnecessary medications in a sample of 34. Findings include: The facility's Antibiotic Stewardship policy, revised 12/18/19, documents that the purpose of the program is to reduce inappropriate use of antibiotics, improve resident outcomes and lessen adverse events. R69's current Physician Order Sheet, documents an order for Cephalexin (antibiotic) 250 milligrams daily for prophylactic antibiotic for frequent UTI's (urinary tract infection). This form also documents a diagnosis of long term (current) use of antibiotics. R69's medical record does not contain documentation or a rationale for the continued use of antibiotic therapy. On 4/30/25 at 8:45 AM, V2, Director of Nursing, verified that R69 does not have the documentation or rationale for the continued use of an antibiotic.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-05-30 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to provide a clean and sanitized floor in the facility kitchen. This failure has the potential to affect all 99 residents who receive food from the kitchen. Findings include: On 5/30/24 at 10:00am, V3 Dietary Manager stated that all (99) residents in the facility receive food from the kitchen. On 5/28/24 at 9:33am, a tour of the facility kitchen found built-up brown/black discolored grease, grime, and debris on the floor in front of both sides of the food preparation table, stove, and throughout other areas in the kitchen. At that time, V3 Dietary Manager stated that the floor guy had already done the floors that morning and that's the way it still looks. V3 stated the kitchen staff are also supposed to mop the floor every evening. An undated posted kitchen sign in the kitchen documents: Nightly Checklist before leaving: Floors swept and mopped. On 5/29/24 at 9:10am, the kitchen floor was free of the built-up grime and debris, however stains of where the grime and built-up grease had been remained. At that time,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · D2024-05-30 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Advanced Directives were documented correctly in the resident's clinical record for one (R17) of two residents reviewed for Advanced Directives in a sample of 40. Findings include: The facility's Practitioner Orders for Life-Sustaining Treatment (POLST), revised 12/02, documents Policy: The facility will establish and follow a set cardiopulmonary resuscitation procedure. Purpose: To establish the decision-making process that will institute or stop cardiopulmonary resuscitation. Procedure: 7. Notations regarding this decision will be made in the resident's medical chart by Nursing. R17's Face sheet documents Advanced Directive: Full Code. R17's current Physician Order Sheet/POS documents Full Code status. The facility's Shift Notes (report sheet for nurses) for R17's hall documents all residents' code statuses; R17's is listed as Full Code. R17's POLST documents DNR (Do Not Resuscitate) and was signed on [DATE] by R17. On [DATE], at 2:15pm V4…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-30 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to include indwelling urinary catheter with cares on a Baseline Care Plan for one (R257) of 21 residents reviewed for Care Plans in a sample of 40. Findings include: The facility's Care Plan Policy, revised 11/28/19, documents Policy: It is the policy of this facility to develop and implement a Base Line Care Plan, a Comprehensive Person-Centered Care Plan and conduct Care Plan Meetings as appropriate for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Explanation and Compliance Guidelines: Base Line Care Plan: Base Line Care Plan: 1. The baseline care plan will: a. Within 48 hours of a resident's admission, the admitting nurse, or supervising nurse on duty, shall develop the Baseline Care Plan by gather information from the admission body assessment,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-30 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to revise a Comprehensive Care Plan for one resident (R7) of 21 residents reviewed for Care Plan revision in a sample of 40. Findings includes: The facility's Care Plan Policy dated 6/1/22 documents: It is the policy of this facility to develop and implement a Base Line Care Plan, a Comprehensive Person-Centered Care Plan and conduct Care Plan Meetings as appropriate for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 3. In the event that the comprehensive assessment and comprehensive care plan identified a change in the resident's goals, or physical, mental, or psychosocial functioning, which was otherwise not identified in the baseline care plan, those change shall be incorporated into an updated summary provided to the resident and his or her representative, if applicable. 10. The comprehensive care plan will include…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-30 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to change gloves and sanitize between glove changes during Indwelling Urinary Catheter cares for one (R257) of three residents reviewed for Catheters in a sample of 40. Findings include: The facility's Infection Control policy, revised 11/28/19, documents Standard Precautions: Standard Precautions are based upon the principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents. Standard Precautions should be applied to the care of all residents regardless of the suspected or confirmed presence of an infectious agent. Standard Precautions include but are not limited to: 1. Hand hygiene .3. Proper use of PPE (Personal Protective Equipment) (gloves, gowns, mask, etc.) .Gloves, disposable in nature, will be worn unless sterile gloves are necessary. Gloves will be changed after direct contact with resident's secretions or excretions, even if care of resident has not been completed. R257's current Physician Order Sheet/POS…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-30 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to obtain weekly weights as ordered by the physician for one of two residents (R92) reviewed for nutrition in the sample of 40. Findings include: The facility's Weight Monitoring Policy revised 6/21 states, Objective: To consistently assess residents for significant weight loss or gain. This same policy documents weekly and monthly weights are recorded by dietary in the resident's electronic medical record. R92's Face Sheet documents R92 admitted to the facility with diagnoses to include but not limited to: Cerebral Infarction; Dysphagia; and Gastrostomy Status. R92's current Physician Orders documents orders for the following: Osmolite 1.5 Cal (Calorie) Nutritional Supplement via Gastric Tube; Free Water Flushes via Gastric Tube; Daily Supplement Shakes; and Weekly Weights. R92's Vitals Weight Summary documents a weight of 215.8 pounds on 5/8/24. As of 5/30/24, no further weights are documented in R92's medical record. On 5/30/24 at 10:43 AM, V3 (Dietary Manager) stated V3 was not aware of R92 having weekly weights ordered.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-30 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure a resident's oxygen humidifier bottle was not empty while in use for one (R254) of one resident reviewed for Oxygen in a sample of 40. Findings include: The facility's Oxygen Therapy policy, revised 05/12, documents Objective: 1. To provide a source of oxygen to persons experiencing an insufficient supply of same .Procedure: 2. Assemble equipment at bedside: a. Humidifier bottle attached to tank flow meter and filled to appropriate level with sterile distilled water. This policy also states, Safety Factors: 1. Must have Oxygen in Use sign posted in space that is visible prior to actually entering room. On 5/28/24, at 9:26am, R254 sat in a wheelchair in her room wearing oxygen per nasal cannula via a portable oxygen tank. The oxygen concentrator next to R254's bed contained an empty, undated, humidifier bottle. R254 stated I use that one (concentrator) mostly at night. R254's room does not have an Oxygen in Use sign at the door. R254's current Physician Order Sheet/POS includes an order dated 5/22/24…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-30 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to provide an appropriate indication for use for an antipsychotic medication, failed to identify target behaviors, and failed to identify non-pharmacological interventions for one (R2) of five residents reviewed for unnecessary medications in the sample of 40. Findings include: Facility Policy/Psychopharmacologic Drug Usage procedure, dated 10/18/17, documents: Documentation of behaviors and conditions requiring the use of these medications must be done on a routine basis, as well as medication response and adverse consequences. Psychopharmacological medication usage must also be addressed in the Care Plan, including appropriate goals, likely medication effects, and potential for adverse consequences. R2's Current Physician's Orders, with an order date of 4/3/24, documents R2 receives Risperidone (antipsychotic) 0.5mg (milligrams) at bedtime for Vascular Dementia with Other Behavioral Disturbance. R2's Behavior monitoring/tracking documentation record dated 4/3/24 - 5/30/24 does not identify specific behaviors to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-30 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precaution/EBP signage was posted and PPE (Personal Protective Equipment) was available for two (R257 and R25) of nine residents reviewed for Infection Control in a sample of 40. Findings include: The facility's Enhanced Barrier Precautions/EBP policy, undated, documents Policy: It is the policy of the facility to use proper PPE (Personal Protective Equipment) during high-contact resident care activities that provide opportunities for transfer of MDROs (Multi-drug resistant organisms) to staff hands and clothing. Purpose: The purpose of the program is to prevent the indirect transfer of MDROs from resident-to resident during high-contact care activities using EBP (Enhanced Barrier Precautions). Key Points: 1. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multi-drug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. 2. EBP are used in conjunction with standard…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-27 · tag F0660 — isolated
    Plan the resident's discharge to meet the resident's goals and needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy to ensure that an effective discharge plan was developed and implemented. The facility also failed to ensure that referrals were made to the appropriate community resources at the time of discharge for one of four residents (R1) reviewed for discharge planning in the sample of four. Findings include: The facility's Discharge Planning, Process, and Procedure revised 9/23 documents the objective is to assist the resident in attaining a safe transition back to the community. This same procedure states, 6. The resident's individualized discharge plan shall be discussed from a multidisciplinary perspective during the Medicare meeting. 7. The Admissions/Social Service Director shall then communicate post discharge needs to the nurse. 8. Medical considerations are to be made and teaching and training related to medical equipment, post discharge care, etc. shall be provided to the resident by qualified nursing staff prior to discharge from…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-04-27 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review and observation, the facility failed to ensure that equipment in the kitchen was clean and free of debris. This has the potential to affect all 84 residents residing in the facility. Findings include: The facility's Bag-In-Box Juice Dispenser Procedure, dated 08/2019, documents Daily cleaning, dispensing gun: Detach the black nozzle from the dispensing gun by twisting it gently pulling down, then soak both the nozzle and dispensing gun in lukewarm water for 10-15 minutes. This form also documents that if the diffuser area (exposed when the nozzle is removed) appears to have residue, clean with a small gentle brush like a soft toothbrush. The Dining Services Department Daily Cleaning Schedule, undated, documents to clean the following equipment after each use: Oven (wipe down) inside and out. On 4/24/23 at 9:45am, a tour of the facility's kitchen was conducted with V13 (Dietary Manager). The left convection oven contained a black, burnt, crusty substance present throughout the floor of the oven, and a brownish-sticky substance was observed running…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-27 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to revise a resident's care plan for one resident (R15) out of 19 residents reviewed for care plans in a sample of 47. Findings include: R15's current care plan documents Has history of skin cancer, followed by Veteran's Affairs, no treatment/just monitor and continue to remove lesions. Keep fingernails clean and trim to reduce risk of impaired skin integrity related to scratching self. On 04/24/23 at 2:00 PM, V8 (Licensed Practical Nurse/LPN) stated I tried cutting his nails, but I only got a couple cut, then he refused to let us cut the rest. When he doesn't let us cut them, we have to re-approach and try again. Other than that, I'm not sure what else we can do. That's something you'll have to talk to the care plan coordinator (V9) or V2 (Director of Nursing/DON) about. On 04/26/23 at 11:04 AM, V9 (Care Plan Coordinator), stated After we implement a care plan intervention, we follow up in one to two weeks to see if the care plan intervention was effective. I was not aware that he was refusing to have his nails trimmed. I…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-27 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to keep a resident's fingernails trimmed to reduce the risk of impaired skin integrity for one resident (R15) out of one resident reviewed for skin conditions in a sample of 47. Findings include: The facility's Personal Care of Residents policy revised 12/02 documents 1. Each resident shall have proper daily personal attention and/or care, including skin, nails, hair and oral hygiene, in addition to treatment ordered by the physician. R15's medical record documents a diagnosis of malignant neoplasm of skin. R15's brief interview of mental status (BIMS) documents a score of 11. A score of 8-12 indicates moderately impaired cognition. R15's medical record dated 3/29/23 documents Weekly skin check complete, scattered scabbing remains to bilateral lower extremities, bilateral upper extremities and face. Resident frequently picks at scabs. Resident instructed to refrain from removing scabs due to increased risk of infection. Resident verbalizes understanding. No reddened areas noted to buttocks, skin prep applied to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-27 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, observation and record review, the facility failed to ensure a resident with limited range of motion was provided appropriate treatment and services to maintain and/or prevent a further decrease for one of four residents (R74) reviewed for limited range of motion in the sample of 47. Findings include: On 04/24/23 at 11:25 AM, V12 (R74's daughter) was sitting in a chair at R74's bedside while R74 was asleep in a low bed. V12 stated she is unsure if R74 is receiving range of motion exercises at this time. On 04/25/23 at 02:15 PM, R74 was sitting in a high-back reclining wheelchair with her knees slightly bent and raised toward her chest. R74 was pleasantly confused and stated Ok when asked how she was doing. R74's call light was within her reach, and a full mechanical lift sling was in place underneath of R74. R74's Minimum Data Set Assessment (dated 02/15/23), Section G, documents the following: R74 has impairment on one side of her upper extremities; and R74 requires total dependence with transfers, dressing, eating, toilet use, personal hygiene, and bathing.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-27 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, observation and record review, the facility failed to ensure an indwelling urinary catheter was secured for one of two residents (R50) and failed to keep an indwelling suprapubic catheter drainage bag and tubing off the floor for one of two residents (R48) reviewed for indwelling urinary catheters in the sample of 47. Findings Include: 1. The facility's Catheter Care policy (revised 05/06) documents the following: Secure the catheter to the thigh and/or lower abdomen in men to facilitate flow of urine and prevent excessive tension on the catheter. On 04/24/23 at 11:20 AM, R50 was sitting in a chair next to her bed. An Indwelling urinary drainage bag inside of a dignity bag was hanging on the lower aspect of R50's bed. R50 stated she has an indwelling urinary catheter, and has had it, a long time. Clear urine was noted in R50's drainage tubing. R50's current Physician's Orders document the following order: Foley catheter care every shift. Monitor that Foley is draining urine to gravity and anchored to person. R50's Progress Note (dated 04/24/23) documents the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-27 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a dementia specific plan of care for one of two residents (R197) reviewed for dementia care in the sample of 47. Findings include: The facility's How To-Write a Care Plan for Mood/Behavior and Psychotropic Meds policy, dated 3/20, documents, Problem Statement-The Problem Statement shall contain a description of the problem, statements made by the resident, the behaviors that are displayed, as well as the baseline amount of behaviors and any identified triggers. If no Mood/Behavioral issues are currently being displayed, a discussion of the mood/behavior history shall be included in the problem statement. The facility's How To-Care plan for Cognition, Vision, Hearing/Communication policy, dated 3/20, documents, Addressing Cognition, Vision, Hearing and Communication in the care plan differs from traditional care planning in that they are typically not addressed through a goal, goal, and approach format. Because there is no way to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to RESIDENTIAL ALTERNATIVES OF ILLINOIS — 7 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.0+1.0 vs chain
Health inspection 4 of 53.3+0.7 vs chain
Staffing 3 of 53.1-0.1 vs chain
Quality measures 3 of 52.1+0.9 vs chain
The other 6 homes this chain runs (chain average 3.0★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
RESIDENTIAL ALTERNATIVES OF ILLINOIS INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/03/2005
DIAZ, JENEIFERIndividualW-2 MANAGING EMPLOYEEsince 04/13/2022
KEMPINERS, WILLIAMIndividualCORPORATE DIRECTORsince 10/11/2013
KNIERY, JOHNIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 08/24/2018
MCMAHAN, BENJAMINIndividualCORPORATE DIRECTORsince 08/24/2018
SHAW, JEFFREYIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 10/11/2013
WILSON, RONALDIndividualCORPORATE OFFICERsince 08/24/2018

CMS files one row per role, so the 9 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$13.1M
Net patient revenuemost recent cost report
+11.3%
Operating marginrevenue minus expenses
$813K
Related-party expense7% of expenses
Who pays — share of resident-days
Medicaid 38%Medicare 20%Other / private 43%

This home reported $813K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$344per resident / day
operating cost
$10,459per month
≈ monthly operating cost
$388per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in IL

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.

Typical monthly cost in Illinois
$8,304/mo
Nursing home (semi-private)
$9,216/mo
Nursing home (private)
$6,219/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 146083. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-30, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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