Winning Wheels
701 East 3rd Street, Prophetstown, IL 61277 · Non profit - Corporation · 88 certified beds · (815) 537-5168 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- CMS has flagged it for abuse
- it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Dec 2025
- 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
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (53) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $12,258 in federal fines (most recent 2024-05-01)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 |
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 1 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 6.9% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.1% | 6.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 2.1% | 1.5% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 15.8% | 54.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.8% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 4.9% | 14.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 26.2% | 18.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.8% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 23.8% | 20.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 24.2% | 21.7% | 17.1% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.21 | 2.02 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.69 | 2.22 | 1.80 | typical |
‡ 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.
Therapy staffing: this home’s payroll records show 0.10 therapist hours per resident per day in 2026Q1 — more than 6% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 22% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 discharge | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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
How full it usually is: this home is certified for 88 beds and averages 69.5 residents a day — about 79% occupied, or roughly 18 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 3.78 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.552 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.54 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 3.53 hrs/resident/day on weekends vs 3.87 on weekdays — 9% thinner on weekends. RN hours go from 0.63 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 51% is about the same as 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
Deficiencies are more than at the previous inspection — worsening. 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.
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.
53 citations, most serious first. The 15 most serious are shown; the remaining 38 are one tap away and print in full.
- Immediate jeopardy · Jcited before2024-05-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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 supervise a resident with exit-seeking behaviors to prevent her from eloping from the building unsupervised. This failure resulted in R1 eloping from the facility and being able to reach a heavily traveled highway. This applies to one of three residents (R1) reviewed for the safety in the sample of 8. The Immediate Jeopardy began on 4/24/24 when R1 was able to elope from the facility. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 4/30/24 at 12:50 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 5/1/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The facility face sheet for R1 shows diagnoses to include hypoxic ischemic encephalopathy (type of brain damage caused by a lack of oxygen to the brain), major depression…
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.
- Actual harm · Gcited before2026-02-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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 ensure hot liquids were safely served and failed to ensure a process was in place for hot liquids for 1 of 3 residents (R5) reviewed for safety in the sample of 8. This failure resulted in R5 spilling his coffee on his lap and sustaining two partial thickness burns to his left inner knee causing R5 pain.The findings include:R5's face sheet showed his most recent readmission to the facility on 1/11/25 with diagnoses to include acute and chronic respiratory failure with hypoxia, atherosclerotic heart disease, chronic cough, dysphagia, epilepsy, hemiplegia and hemiparesis, and mononeuropathy of left lower limb. R5's facility assessment dated [DATE] showed he has no cognitive impairment and requires substantial to maximum assist for most cares.R5's 2/3/26 Nurse's Note entered at 9:22 AM showed, Resident spilled hot coffee at 7:45 AM on left knee during breakfast. Area cleaned, TAO (triple antibiotic ointment) applied and covered with dressing.…
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.
- Actual harm · Gcited before2025-05-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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 safety measures were implemented for three residents (R1, R2, R3) who fell during cares and/or transfers of three residents reviewed for falls. This failure resulted in R1 sustaining a fractured left humerus. The findings include: Facillity Policy/Safety and Supervision, last revision date 02/2025, documents: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include: Bed/Chair Safety; Safe Lifting and Movement of Residents. Facility Policy/Managing Falls and Fall Risk dated 2001 documents: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try 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.
- Actual harm · G2023-11-02 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
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 administer a resident's pain medication as ordered, failed to manage a resident's pain at a comfortable level, and failed to obtain emergency doses of a resident's pain medication when it was unavailable. These failures resulted in R12's Norco supply becoming depleted, R12 missing 16 doses of a prescribed narcotic pain medication, and R12 experiencing increased pain levels. The findings include: R12's electronic face sheet printed on 11/2/23 showed R12 has diagnoses including but not limited to intracranial injury with loss of consciousness, hemiplegia, encephalopathy, epilepsy, contractures, and behavioral syndromes. R12's facility assessment dated [DATE] showed R12 has severe cognitive impairment and experiences pain almost constantly. R12's care plan dated 7/8/20 showed, The resident is on pain medication therapy due to lower back pain. Administer analgesic medications as ordered by physician. Monitor/document side effects and effectiveness every…
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.
- Actual harm · Gcited before2023-08-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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 ensure a resident was free from abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 3. This failure resulted in R2 feeling unsafe and in fear of R3. The findings include: R2's face sheet printed on 8/1/23 showed he was admitted to the facility on [DATE] with diagnosis including but not limited to injury at the C4 level of cervical spinal cord and paraplegia. The facility assessment dated [DATE] showed no cognitive impairment. The same assessment showed R2 needs extensive staff assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. On 8/1/23 at 9:15 AM, R2 was lying in bed with a lap top device and cellular phone on the table over him. R2 was fully alert and oriented. R2 said there are a lot of wandering residents, but one that is especially bad (R3). He is in the room right next door to me and comes in here yelling and cussing. He has brain issues and once I even saw him eating his own…
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.
- Potential for harm · Fcited before2026-02-05 · tag F0925 — failed to control pests — widespreadMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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 implement it's pest control policy. This failure has the protentional to affect all residents residing in the facility. The findings include:The facility census provided on 2/4/26 but dated 2/1/26 showed 74 residents reside in the facility. On 2/5/26 at 11:55 AM, R4 stated there were mouse dropping in her dresser in October of 2025. R4 then presented a photograph on her laptop. The photograph showed her dresser with small mouse droppings and what appeared to be crystalized urine. R4 said, It was disgusting and a real disease problem. Mice carry diseases. On 2/4/26 at 11:40 AM, R8 said, I've never had any issues with seeing mice but there have been mouse droppings on my bed. The last time I saw mouse droppings was last week. On 2/4/26 at 1:35 PM, V10 Environmental Services Director stated the facility employs a third-party pest elimination contractor. V10 stated the contractor generates a report stating trouble areas with the building; areas where bugs and rodents can enter the facility. V10 was shown 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.
- Potential for harm · Dcited before2026-01-27 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 check placement of a narcotic pain patch as ordered for 1 of 3 residents (R1) reviewed for patch placement and administration.The findings include:R1s admission record shows he was admitted on [DATE] with multiple diagnoses including other chronic pain and unspecified pain. The January Medication Administration Record (MAR) shows a 11/10/24 order for Fentanyl patch 25 mcg (micrograms)/hour every 72 hours. Apply 1 patch trans dermally (to the skin) every 72 hours for pain. Rotate site and remove per schedule. The MAR also shows an order for Fentanyl Patch placement check every shift. The checks were scheduled for day and night shift. The MAR shows the checks were completed on 1/21/26 for both shifts. On 1/27/26, R1 was observed to have a Fentanyl patch located on his left chest. The patch was dated and initialed by the nurse. The facility incident report of 1/21/26 documents V2 Director of Nursing was notified by nurses during the night…
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.
- Potential for harm · Ecited before2025-12-21 · tag F0602 — failed to protect residents from theft of their belongings — patternProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to protect 6 residents (R1,R2,R3,R4,R5,R6) from misappropriation of medications. This applies to 6 of 6 residents reviewed for misappropriation in the sample of 14. The findings include:The facility's investigation dated 10/8/25 showed, Between 9/29-9/30 from 11:55PM until about 4:00AM, (V5) is seen in the medication room sleeping. Around 4:00AM, (V5) is seen on (unit) with her medication cart. She can be seen in the medication drawer dispensing medications from the cards into her bare hands and then putting them into a cup. During this time, (V5) is not seen at any point looking at the EMAR (Electronic Medication Administration Record) .At approximately 5:07AM after pulling medications she is seen putting something in her mouth. Approximately 5:14AM she is seen going through the narcotic box and pulling medications from the cards into her bare hands. It then appears that she puts something in her left front pocket of her hoodie that she is wearing. At 6:00AM, she is seen going through the narcotic box and (Narcotic…
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.
- Potential for harm · Ecited before2025-12-21 · tag F0609 — failed to report abuse allegations — patternTimely 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, failed to report alleged violations of misappropriation for 6 residents (R1, R2, R3, R4, R5, R6) to IDPH (Illinois Department of Public Health) within 24 hours, failed to implement policies and procedures for reporting the possible crime to law enforcement. These failures apply to 6 of 6 residents reviewed for misappropriation in the sample of 14. The findings include:The facility's investigation dated 10/8/25 showed, Between 9/29 to 9/30 from 11:55PM until about 4:00AM, (V5-Licensed Practical Nurse-LPN) is seen in the medication room sleeping. Around 4:00AM, (V5) is seen on (unit) with her medication cart. She can be seen in the medication drawer dispensing medications from the cards into her bare hands and then putting them into a cup. During this time, (V5) is not seen at any point looking at the EMAR (Electronic Medication Administration Record) .At approximately 5:07AM after pulling medications she is seen putting something in her mouth. Approximately 5:14AM she is seen going through the narcotic box and pulling medications from the cards…
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.
- Potential for harm · Ecited before2025-12-21 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure medications were administered per physician's orders for 4 of 6 residents (R4, R5, R6, R14) reviewed for pharmacy services in the sample of 14. The findings include:The facility's incident report dated 10/8/25 showed, On 9/30/25 at 7AM, V1 (Administrator) received a phone call from Director of Nursing, stating that it was reported to her that the agency night nurse (V5-Licensed Practical Nurse) had slept most of the night. Concerns were brought up that (V5) did not complete her wound treatments, failed to sign out medications in EMAR (Electronic Medication Administration Record) .2 residents were identified to have not received their scheduled medications .R4's September 2025 MAR (Medication Administration Record) showed R4 receives Amantadine 100mg, fluoxetine 10mg, lactulose 15ml, omeprazole 20mg, baclofen 10mg, buspirone 5mg, diazepam 5mg, levetiracetam 1000mg, Norco 5/325mg at 5:00AM. No documentation was present showing R4 received his 5:00AM medications from V5 on 9/30/25.R5's September 2025 MAR showed R5…
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.
- Potential for harm · Fcited before2025-07-23 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a meal was served in a sanitary manner and failed to ensure the temperature of resident refrigerators were monitored. This has the potential to affect all 77 residents residing in the facility. The findings include: 1. On 7/21/25 at 11:30 AM, V15 (Cook) was plating the noon meal from the steam table. V15 had gloves on and was putting the fish sticks and cornbread onto the plates using her hands. At 11:45 AM, V15 coughed onto her right wrist area. At 11:49 AM, V15 sneezed into her left elbow area. At 11:51 AM, V15 wiped her nose with her left wrist area. V15 continued to serve the food with her hands and did not remove her gloves and perform hand hygiene. On 7/22/25 1:10 PM, V4 (Dietary Manager) said that staff should always be using utensils to serve food to the residents. V4 said that if the staff coughs or sneezes while plating food, they should leave the line and wash their hands and put a new pair of gloves on. The facility'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.
- Potential for harm · E2025-07-23 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
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 follow the pureed diet menu for 4 of 4 residents (R4, R16, R38 and R42) reviewed for menus in the sample of 18. The findings include:The facility provided Diet Type Report printed on 7/22/25 shows that R4, R16, R38 and R42 are all on a pureed diet.The Diet Spreadsheet for the noon meal on 7/21/25 shows that residents on a pureed diet should receive pureed barbecue on cornbread, pureed green beans and pureed canned fruit.The Recipe for Pureed Barbecue Pork on Cornbread shows ingredients of: BBQ Pork on cornbread with creamed corn and milk.On 7/21/25 at 10:42 AM, V15 (Cook) prepared the pureed food for the noon meal. V15 placed 10 scoops of barbecue pork into the blender bowl and processed it. V15 added warm milk and processed again. V15 then place the pureed barbecue into a container and placed it onto the steam table. V15 did not add cornbread to the barbecue. On 7/21/25 at 11:37 AM, R4, R16, R38 and R42 were served the pureed barbecue without a cornbread serving. V15 then ran out of pureed barbecue and…
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.
- Potential for harm · E2025-07-23 · tag F0805 — failed to prepare food in a form residents can eat — patternEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
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 residents on a pureed diet were served a meal in a form that meet their needs for 4 of 4 residents (R4, R16, R38 and R42) reviewed for pureed diets in the sample of 18. The findings include:The facility provided Diet Type Report printed on 7/22/25 shows that R4, R16, R38 and R42 are all on a pureed diet.The Diet Spreadsheet for the noon meal on 7/21/25 shows that residents on a pureed diet should receive pureed barbecue on cornbread, pureed green beans and pureed canned fruit and an alternative of pureed breaded fish and pureed potatoes. On 7/21/25 at 10:42 AM, V15 (Cook) prepared the pureed food for the noon meal. V15 pureed breaded fish sticks and added warm milk. V15 then placed the pureed fish into a container. When scooped into the container, the fish appeared very thick. V15 then pureed barbecue pork and added warm milk. V15 then placed the barbecue into a container. When scooped into the container, the barbecue appeared thick. On 7/21/25 at 11:37 AM, R4, R16, R38 and R42 were served the pureed…
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.
- Potential for harm · D2025-07-23 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review the facility failed to ensure psychotropic medications were prescribed for a defined duration for 1 of 5 residents (R12) reviewed for unnecessary medications in the sample of 18.The findings include:R12's Order Summary Report dated 7/23/25 shows R12 has an order for a psychotropic medication (Diazepam) to be administered as needed. The start date for the order was 3/10/25. There is no end date. On 7/23/25 at 10:10 AM, V9, MDS Coordinator, said psychotropic medications ordered as needed can only be prescribed for a duration of 14 days, then a new order must be obtained. The facility's Psychotropic Medication Use Policy (undated) shows psychotropic medications are subject to prescribing, monitoring and review requirements; psychotropic medication management includes duration.
- Potential for harm · Dcited before2025-07-23 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
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 complete a Preadmission Screening and Resident Review (PASARR) Level 2 screen after a resident that was diagnosed with schizoaffective disorder diagnoses which applies to 1 of 18 residents (R7) reviewed for PASARR assessments in a sample of 18.The findings include:R7's Facesheet printed on 7/23/25 showed R7 is a sixty-year-old male originally admitted to the facility on [DATE].R7's Physician Summary notes dated 3/31/2020 showed R7's schizoaffective disorder diagnosis onset is dated 4/17/2019.R7's electronic record showed no PASARR level 2 was completed after R7 received the new diagnosis of schizoaffective disorder.The facility's PASARR Policy dated 2024 showed a resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or related conditions will be referred promptly to the state mental health or intellectual disability authority for a level 2 resident review.On 7/23/25 at 2:00 pm, V1 Administrator stated a…
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.
Show the remaining 38 citations
- Potential for harm · Dcited before2025-07-23 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 ensure a dressing was in place for a resident with a stage 4 pressure injury for one of one resident (R71) reviewed for pressure injuries in the sample of 18.The findings include:R71's Order Summary Report dated July 22, 2025 shows he was admitted to the facility on [DATE] with diagnoses including spina bifida, urinary tract infections, wheelchair dependence, pressure injury of left buttock stage four, and malnutrition. Orders for calcium alginate apply to left buttock topically every day shift started July 14, 2025.On July 21, 2025 at 10:18 AM, V8 Certified Nursing Assistant placed R71 into the shower chair and placed him in the shower so he could shower himself. At 10:49 AM, V8 placed R71 back into bed and dried off R71's body and got him dressed. There was a dressing that came off of R71's left buttock. The wound to R71's left buttock had some depth to it and was a little bigger than a quarter size in diameter. V8 put a shirt onto R71…
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.
- Potential for harm · Dcited before2025-07-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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 ensure a resident was transferred in a safe manner for 1 of 18 residents (R73) in the sample of 18 reviewed for safety.The findings include:On 7/21/25 at 11:03 AM, R73 was sitting in a recliner in the TV room. V12, Certified Nursing Assistant (CNA), was pulling R73's left arm to get him out of the recliner. R73's left arm was pulled to the point where his left elbow was above the level of his head. On 7/23/25 at 9:30 AM, V2, Director of Nursing (DON), said a gait belt should be used to help pull a resident out of their chair. A resident's arm should not be pulled because it could cause an injury. R73's admission Record dated 7/23/25 shows he was admitted to the facility on [DATE]. R73's diagnoses include, but are not limited to, traumatic brain injury, quadriplegia, and repeated falls. R73's current care plan provided by the facility shows R73 has limited mobility, decreased strength, history of falls, and decreased sitting and standing…
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.
- Potential for harm · D2025-07-23 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to date and time liquid nutrition when it was initiated for 1 of 4 residents (R34) reviewed for tube feeding in the sample of 18.The findings include:R34's Order Summary dated July 22, 2025 shows R34 was admitted to the facility on [DATE] with diagnoses including intracranial injury with loss of consciousness, dysphagia, pain, contractures, aphasia, and epilepsy. A liquid nutrition order was entered on November 22, 2024 for Isosource 1.5 two times per day.On July 21, 2025 at 9:39 AM, there was a bag of liquid nutrition hanging next to R34's bed. There was no resident's name on the bag nor date nor time. There was liquid nutrition noted in the tubing and the bag of nutrition was half empty. At 1:05 PM, this same unlabeled bag was still hanging next to R34's bed.On July 23, 2025 at 9:27 AM, V2 Director of Nursing said the liquid nutrition should be labeled with the date and time it was hung, the type of liquid nutrition, and the resident'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.
- Potential for harm · Dcited before2025-07-23 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 administer a medication as ordered by the physician for one of 18 residents (R3) reviewed for pharmacy services in the sample of 18. The findings include:R3's Order Summary Report shows she was admitted to the facility on [DATE] with diagnoses including myocardial infarction, congestive heart failure, generalized anxiety disorder, major depressive disorder, pain, major depressive disorder, post-traumatic stress disorder, alcohol use, and other bipolar disorder.On July 22, 2025 at 10:39 AM, R3 said it takes the facility a long time to start new medication orders. R3 said the psych doctor ordered an increase in her trazodone but she did not get the medication when it was ordered. I take it to help me sleep.R3's note from the psychiatry nurse practitioner dated July 10, 2025 shows, Plan Med changes: Patient's diagnosis of major depressive disorder is worsening and unstable at this visit. Increase trazodone to 100mg by mouth at bedtime.R3's Order Summary…
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.
- Potential for harm · D2025-07-23 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
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 multidose insulin pen was discarded 28 days after being opened for 1 of 18 residents (R3) reviewed for medication storage in the sample of 18. The findings include:On 7/21/25 at 10:13 AM, R3's Lispro Insulin Pen was in the medication cart. The pen was labeled with an open dated of 6/15/25 and there was no discard date documented. 07/21/2025 10:13 AM, V7 (Licensed Practical Nurse) said that all insulin pens should be marked with the open date when it is opened and a discard date should be documented for 28 days after the date that it was opened. R3's July Medication Administration Record shows that she received Lispro Insulin Pen five times between 7/13/25 and 7/21/25. The facility's Insulin Pen Policy shows, Insulin pens must be clearly labeled with the resident name, physician name, date dispensed, type of insulin, amount to be given, frequency and expiration date Insulin pens should be disposed according to manufacturer's recommendations. The Lispro Manufacturer Guidelines show, Throw away 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.
- Potential for harm · D2025-07-23 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
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 provide dental services for a resident which applies to 1 of 1 resident (R49) reviewed for dental services in a sample of 18.The findings include:R49's Facility assessment dated [DATE] showed R49 is a thirty-nine-year-old male resident with moderate cognitive impairment. R49 was admitted to the facility on [DATE] with diagnoses which include hemiplegia/hemiparesis and intercranial injury.On 07/21/2025 at 2:00 PM, R49 was sitting in their wheelchair watching television. R49 had several broken teeth on their upper jaw, and dark colored tooth fragments/tooth roots along their lower jaw.R49's electronic medical record showed the last dental consent and appointment notes were dated 10/20/2020.On 7/23/25 at 1:50 PM, V11 Social Services stated we set up in house or out of house services for dental work. R49 does get seen out of the facility for dental services. V11 stated R49 does have broken teeth and gum issues. V11 stated they were not aware…
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.
- Potential for harm · Dcited before2025-07-23 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
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 change their gloves and perform hand hygiene in a manner to prevent cross contamination for one of 18 residents (R34) reviewed for infection control in the sample of 18.The findings include:R34's Order Summary Report dated July 22, 2025 shows she was admitted to the facility on [DATE] with diagnoses including intracranial injury with loss of consciousness, insomnia, dysphagia, atopic dermatitis, and neuromuscular dysfunction of the bladder.R34's Care Plan initiated on April 20, 2020 shows R34 has bowel and bladder incontinence. R34's Care Plan initiated on April 15, 2025 shows R34 is on enhanced barrier precautions and ensure proper hand washing is completed as resident allows.On July 21, 2025 at 9:39 AM, V5 and V6 Certified Nursing Assistants (CNAs) provided incontinence care to R34. V6 CNA removed R34's incontinence brief. There was a large amount of urine in R34's incontinence brief. V6 then touched the mechanical lift sling to place…
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.
- Potential for harm · Dcited before2025-07-23 · tag F0925 — failed to control pests — isolatedMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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 ensure residents rooms were free from pests which applies to 2 of 18 residents (R46, R54) reviewed for pest control is a sample of 18.The findings include:The facility's resident roster dated 7/16/25 showed R46 and R54 are roommates on the B-wing of the facility.R46's Facesheet printed on 7/22/25 showed R46 is a [AGE] year-old male with diagnoses which include tracheostomy, traumatic brain injury, and hemiplegia of the left side.On 7/21/25 at 10:30 AM, R46 was lying in bed with no shirt on. R46 had 4-6 flies flying around bed area and landing and walking on R46. R46 was having difficulty waving the flies off himself. R46 nodded when asked if the flies were bothering him. No pest reduction methods were in the room at this time. There were more than a dozen flies in R49's room at this time.R54's Facesheet printed on 7/22/25 showed R54 is a [AGE] year-old male with diagnoses which include intracranial injury with loss of consciousness,…
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.
- Potential for harm · Dcited before2025-05-20 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 interview and record review, the facility failed to treat a residents (R1) urinary tract infection (UTI) for nearly 48 hours. This applies to 1 of 3 residents (R1) reviewed for improper nursing care in the sample of 5. The findings include: R1's admission Record (Face Sheet) showed an admission date of 8/23/23 with diagnoses to include partial paralysis following a stroke, ESBL (bacteria in the urinary tract that are resistant to many antibiotics), history of urinary tract infections, morbid obesity, and congestive heart failure. R1's 3/26/25 Nurse's Note from 5:05 PM showed, Final report received for urine C&S (culture and sensitivity, a urine test showing which bacteria are present in the urine) . The note showed which bacteria and fungi were present and that R1's doctor, nurse practitioner, and the director of nursing were notified. R1's 3/27/25 Nurse's Note from 11:04 AM showed, (no other progress notes were documented between this note and the previous note listed) Resident in bed sleeping, easily awakened to take scheduled medications. c/o (complains of) urinary…
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.
- Potential for harm · Ecited before2025-02-13 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 controlled medications were signed off in the electronic narcotic inventory system at the time the controlled medications were administered for 7 of 10 residents (R4-R10) in the sample of 10. The findings include: On 2/13/25 between 9:12 AM and 10:20 AM, a medication pass by V4 (Licensed Practical Nurse-LPN) was observed on the B wing of the facility. At 10:20 AM, V4 said she had completed the AM medication pass for the residents she was assigned to, and there were no more residents with AM medications due on the B wing. At 10:47 AM, V4 was informed that this surveyor would like to do a narcotics count with her for the B wing medication cart. V4 said she had to sign off on her narcotics prior to doing the narcotics count. V4 was informed that we would go ahead and do the narcotics count at that time. During the narcotics count, controlled medications for R4-R10 were not signed off in the electronic narcotic inventory system at the time they were administered to R4-R10. The narcotic count showed 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.
- Potential for harm · D2025-01-07 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
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 utilize a glucose monitoring sensor per physician orders for 1 of 3 residents (R1) reviewed for physician orders in the sample of 4. The findings include: On 1/7/25 at 10:12 AM, R1 was in bed watching TV. R1 said she was upset with V7 (Registered Nurse-RN) because she placed her glucose monitoring sensor wrong and now she had to be poked in the finger to check her blood sugar. R1 said this happened over the weekend. R1 said V7 bent the needle and so it had to be removed. R1 said the nurses told her a new one couldn't be used since the insurance wouldn't pay for it. R1 said insurance only pays for 2 per month and now she has to wait 14 days. On 1/7/25 at 10:30 AM, V5 (Licensed Practical Nurse-LPN) said she was told in report that V7 tried to insert the glucose sensor and bent the needle so it wasn't working and had to be removed. V5 said they have to wait for 2 weeks since insurance only covers 2 per month. V5 said she was not sure if V2 (Director of Nursing-DON) was notified but she was going to tell her…
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.
- Potential for harm · Dcited before2025-01-07 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
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 residents received assistance with activities of daily living for 2 of 4 residents (R1, R2) reviewed for activities of daily living (ADL) in the sample of 4. The findings include: 1. On 1/7/25 at 10:12 AM, R1 was in bed watching TV. R1 said staff have to assist her up to her reclining chair since her electric wheelchair is broke. R1 said she can not propel herself in the reclining chair and staff don't like to deal with the chair. R1 said she has a pendant call light to use when she is not in her room for staff to come help her get back to her room. On 1/7/25 at 11:48 AM, R1 was up in her reclining wheelchair in the dining room. R1 did not have her pendant call light on. R1 said she didn't have it on today, and staff usually don't put it on unless she asks for it. R1 said the other day at dinner time, she didn't have her pendant on and staff left her in the dining room. R1 stated they just left me down here! I had to holler out for help! The kitchen staff heard me and went and got someone but is was a…
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.
- Potential for harm · Dcited before2024-07-23 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 interview and record review the facility failed to ensure orders were in place for a resident with non-pressure skin injuries and failed to ensure a resident's central venous catheter dressing was changed weekly. This applies to 2 of 3 residents reviewed for nursing care in the sample 4. The findings include: 1. R1's 6/6/24 Progress Note from 5:00 PM, showed he returned from his wound care appointment with a PICC line. (Peripherally Inserted Central Catheter, a type of Intravenous (IV) catheter which extends to the large veins in the chest.) On 7/23/24 at 1:30 PM, V1 Administrator stated a resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) should include all the resident's orders and treatments. R1's June 2024 MAR and TAR showed no PICC line dressing order being in place; therefore, no PICC line treatments were documented as being done. R1's July 2024 TAR showed, Change PICC line dressing Weekly and PRN (as needed) every day shift every 7 days for infection control. The TAR showed this order was started on 7/9/24 (over a month after…
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.
- Potential for harm · Fcited before2024-06-13 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 prepare and serve food in a clean, sanitary manner. This failure has the potential to affect all of the residents in the facility. The findings include: The CMS 671 form dated 6/11/24 showed 82 residents resided in the facility. The Diet Type Report, printed by the facility on 6/12/24 showed 5 of the 82 residents (R31, R35, R40, R60, and R184) did not take food by mouth. On 6/11/24 at 9:10 AM, the oil in the deep fryer was black. Dark food crumbs were visible around the edges of the fryer, at the top of the oil level. On 6/11/24 at 11:00 AM, V14 (Dietary Cook) was getting ready to serve the lunch meal. V14 was asked to take the temperature of the foods prior to serving. V14 picked up the digital thermometer from the prep table behind her and inserted the thermometer into the orange chicken, and then into the turkey without sanitizing the digital thermometer. At 11:14 AM, V15 ((another Dietary Cook) uncovered two pans that the temperature had not been checked yet. V15 said the items were the pureed and…
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.
- Potential for harm · Ecited before2024-06-13 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. R23's order summary sheet for June 2024 shows an order for enhanced barrier precautions related to history of MDRO (Multiple Drug Resistant Organism) with indwelling devices every day and night shift for infection control management. The order was not started until 6/12/24. On 6/12/24 at 2:00 PM, V3 entered R23's room to complete his dressing change. He had no sign on the door to indicate enhanced barrier precautions, and V3 did not don a gown before performing the dressing change. R23 was observed to have open wounds on his buttocks, an indwelling catheter, and a feeding tube. On 6/13/24 at 8:05 AM, V3 said R23 should be on enhanced barrier precautions due to having a MDRO in his blood and multiple indwelling devices such as his tracheotomy, feeding tube and catheter. He should have signage up on his door and PPE available for staff. She stated when performing his dressing change, she should have been wearing a gown. 3. R31's order summary sheet for June 2024 documents an order for EBP (Enhanced Barrier…
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.
- Potential for harm · D2024-06-13 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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 provide personal care for a resident in a manner to promote dignity for 1 of 1 resident (R49) in the sample of 20. The findings include: R49's admission Record, printed by the facility on 6/12/24, showed he had diagnoses including quadriplegia, C5-C7 incomplete, neuromuscular dysfunction of bladder, neurogenic bowel, polyneuropathy (damage to multiple peripheral nerves resulting in problems with sensation, coordination and other body functions) neuralgia (pain caused by damaged or irritated nerve), neuritis (inflammation of one or more nerves that can lead to impaired transmission of neural signals), and edema. R49's facility assessment dated [DATE], showed he was cognitively intact, had an indwelling catheter and was always incontinent of bowel. R49's functional performance care plan, initiated on 4/20/2020, showed he required extensive assist of two staff members for dressing and bed mobility, and total assist of two staff members for…
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.
- Potential for harm · Dcited before2024-06-13 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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's right to be free from abuse for 2 of 3 residents (R38, R44) reviewed for abuse in the sample of 20 and 1 resident (R25) outside the sample. The findings include: 1. On 6/11/24 at 10:11 AM, R38 was in her room in a wheelchair. She was alert and oriented X3. Her speech was clear and she had good eye contact. On 06/11/24 at 10:11 AM, R38 said on the Saturday of Memorial Day weekend (5/25/24), she and her old roommate (R42) were in their room. R38 said R42 kept interrupting her and she asked her not to. R38 said R42 became defensive and lifted a fist toward her. R38 said R42 then pulled the room separating curtain and hit her with an open hand and hit her in the back of her head. I started yelling and she (R42) left the room. If she was not in here in the facility, she'd be in jail. She assaulted me. I went down the hall and told V11 Registered Nurse (RN) what happened. She (R42) is very aggressive. She blackened another resident's eye…
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.
- Potential for harm · Dcited before2024-06-13 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to investigate an allegation of abuse for 2 of 3 residents (R38, R44) reviewed for abuse in the sample of 20 and 1 resident (R25) outside the sample. The findings include: 1. On 6/11/24 at 10:11 AM, R38 was in her room in a wheelchair. She was alert and oriented X3. Her speech was clear and she had good eye contact. On 06/11/24 at 10:11 AM, R38 said the Saturday of Memorial weekend (5/25/24) her roommate (R42) hit her in the back of the head. R38 said she reported it to V11 Registered Nurse (RN) right afterward and nobody talked to her about it until the following Tuesday (5/28/24). No one from management came in that whole weekend. R38 said on 5/28/24 around 11:00 AM, V1 Administrator asked how her weekend was. I told her it was fine before the incident. R38 said V1 did not seek her out for any additional questioning but she sought her out later and eventually talked with her about the incident. I told her what happened and that R42 keeps coming and touching me. R38's 4/30/24 facility assessment showed she was cognitively…
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.
- Potential for harm · Dcited before2024-06-13 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
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 a Level 2 PASRR (Pre-admission Screening and Resident Review) for 2 of 5 residents (R61,R67) reviewed for PASRR screening in the sample of 20. The findings include: 1) R61's electronic face sheet printed on 6/13/24 showed R61 has diagnoses including but not limited to schizophrenia and depression. R61's document titled, Notice of PASRR Level 1 Screen Outcome dated 9/26/22 showed R61 does not require a Level II PASRR and has no mental health diagnosis. 2) R67's electronic face sheet printed on 6/13/24 showed R67 has diagnoses including but not limited to schizophrenia and bipolar disorder. R67's document titled, Notice of PASRR Level 1 Screen Outcome dated 1/25/24 showed R67 does not require a Level II PASRR and has no mental health diagnosis. On 6/13/24 at 12:04PM, V1 (Administrator) stated, PASRR's are done prior to admission, if there are changes while they are here then we would do a new one. R61 and R67 have not had a Level 2 done. The system says they don't need one. I know it's our responsibility to get them…
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.
- Potential for harm · Dcited before2024-06-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
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 provide feeding assistance to 1 of 1 residents (R37) reviewed for activities of daily living (ADL's) in the sample of 20. The findings include: R37's electronic face sheet printed on 6/13/24 showed R37 has diagnoses including but not limited to cerebral palsy, dysphagia, major depressive disorder, diaphragmatic hernia, and gastroesophageal reflux disease. R37's facility assessment dated [DATE] showed R37 has no cognitive impairment, dependent on staff for eating, and has a mechanically altered diet. On 6/12/24 at 10:45AM, during the resident council meeting R37 stated, There was a night last week where I didn't get fed dinner. I need assistance with all of my meals because I can't move my arms to reach my mouth. I eat dinner in bed because I have a lot of pain so I only eat breakfast and lunch in the dining room most of the time. The staff brought a tray to my room and then left it there and never came back to help me eat. The facility's form titled,…
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.
- Potential for harm · Dcited before2024-06-13 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to identify a resident's skin concern, assess the area, and start a treatment for 1 of 1 resident (R49) reviewed for skin concerns in the sample of 20. The findings include: R49's admission Record, printed by the facility on 6/12/24, showed he had diagnoses including quadriplegia, C5-C7 incomplete, neuromuscular dysfunction of bladder, neurogenic bowel, polyneuropathy (damage to multiple peripheral nerves resulting in problems with sensation, coordination and other body functions) neuralgia (pain caused by damaged or irritated nerves), neuritis (inflammation of one or more nerves that can lead to impaired transmission of neural signals), and edema. R49's facility assessment dated [DATE], showed he was cognitively intact, had an indwelling cather, was always incontinent of bowel and was at risk of developing pressure ulcers/injuries. R49's functional performance care plan, initiated on 4/20/2020, showed he required extensive assist of two…
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.
- Potential for harm · Dcited before2024-06-13 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 prevent a medical device related pressure injury and failed to identify an area of pressure prior to becoming a Stage 3 for 2 of 4 residents (R32, R23) reviewed for pressure in the sample of 20. The findings include: R32's face sheet showed a [AGE] year-old male with diagnosis of spina bifida, obstructive sleep apnea, chronic kidney disease stage 3, neuromuscular dysfunction of the bladder, klebsiella pneumoniae infection, presence of a cerebrospinal fluid drainage device, dependence on a wheelchair and history of urinary tract infections. On 06/11/24 at 09:30 AM, R32 was on his back in bed. R32 had an indwelling urinary catheter. There was a catheter securing device to his right anterior thigh. R32's catheter tubing was not in the device but over his left thigh and attached to a urinary drainage bag. R32's penile shaft was disfigured by a split in the shaft beginning at the distal (entry) end downward. The skin on both sides of the split…
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.
- Potential for harm · D2024-06-13 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident's splint was applied to prevent further limited range of motion for 2 of 4 residents (R19, R30) reviewed for limited range of motion in the sample of 20. The findings include: 1) R19's electronic face sheet printed on 6/13/24 showed R19 has diagnoses including but not limited to hemiplegia affecting left non-dominant side, traumatic brain injury, edema, mild cognitive impairment, and localized swelling of left limb. R19's facility assessment dated [DATE] showed R19 has severe cognitive impairment, no rejection of cares, upper and lower extremity impairment, and requires splint or brace assistance 7 days a week. R19's care plan dated 4/14/20 showed, Decrease in functional range of motion in my BLE (bilateral lower extremity) and LUE (left upper extremity). Apply L (left) WHO (wrist, hand, finger orthosis) for 8 hours daily for contraction management. R19's physician's orders dated 9/21/23 showed, left WHO on for up to 4…
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.
- Potential for harm · Dcited before2024-06-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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 safely transfer a hospice resident using a gait belt for 1 of 1 resident (R76) reviewed for transfers in the sample of 20. The findings include: R76's admission Record, printed by the facility on 6/12/24, showed she had diagnoses including cerebral infarction (stroke), chronic obstructive pulmonary disease, polyneuropathy (damage to multiple peripheral nerves resulting in problems with sensation, coordination and other body functions), hypertension, osteoarthritis of bilateral knees, dyspnea (shortness of breath), restlessness and agitation, pain and edema. R76's facility assessment dated [DATE] showed she had short-term memory problems and modified independence in cognitive skills for daily decision making. The assessment showed R76 required substantial/maximal assistance with transfers from chair-to-bed, and bed-to-chair. On 6/11/24 at 12:42 PM, V19 CNA (Certified Nursing Assistant) entered R76's room to transfer her into bed after 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.
- Potential for harm · Dcited before2024-06-13 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to keep a urinary drainage bag below the level of the bladder and failed to prevent a urinary drainage bag from contact with the floor for 1 of 2 residents (R28) reviewed for catheters in the sample of 20. The findings include: R28s face sheet showed a [AGE] year-old male with diagnosis of intracranial injury, protein-calorie malnutrition, retention of urine, chronic peripheral venous insufficiency, neuromuscular dysfunction of the bladder, convulsions, dementia, history of urinary tract infections, acquired absence of a kidney, and carrier or suspected carrier or methicillin resistant staphylococcus aureus. On 06/11/24 at 02:18 PM, R28 was in his bed. R28's catheter drainage bag and tubing were in contact with the floor and not in a dignity bag. On 06/12/24 at 08:33 AM, V7 Certified Nursing Assistant (CNA) assisted R28 to reposition to his left side while in bed. R28 was supine. V7 removed R28's urinary drainage bag from the bed frame,…
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.
- Potential for harm · Dcited before2024-05-01 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 ensure a resident (R4) was free from sexual abuse (by R5) for 1 of 8 residents reviewed for abuse in the sample of 8. The findings include: The facility incident report sent to the Illinois Department of Public Health showed on 4/27/24 that R5 touched R4's breast while both were sitting outside on the front patio. R4's computerized face sheet printed on 4/30/24 showed diagnosis including but not limited to paraplegia and malignant neoplasm of spinal cord. R4's facility assessment dated [DATE] showed no cognitive impairment and no memory problems. R4's assessment showed the use of a manual wheelchair and the ability to operate it independently. R5's computerized face sheet printed on 4/30/24 showed diagnoses including but not limited to multiple sclerosis, paraplegia, and cognitive communication deficit. R5's facility assessment dated [DATE] showed moderate cognitive impairment and no upper extremity impairment. R5's assessment showed 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.
- Potential for harm · Dcited before2024-05-01 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 report an allegation of abuse. This applies to one of three residents (R1) reviewed for abuse in the sample of 8. The findings include: The facility face sheet for R1 shows diagnoses to include hypoxic ischemic encephalopathy (type of brain damage caused by a lack of oxygen to the brain), major depression disorder with psychotic features, anxiety, dementia and cardiomyopathy. The brief interview for mental status (BIMS) dated 2/19/24 shows R1 cognitively intact. R1's facility assessment shows her to be able to walk independently. On 4/26/24 at 11:43 AM, V2 Director of Nursing said R1 was taken to the hospital on 4/24/24 after she eloped from the facility and became aggressive with the staff. V2 said the facility was notified from the hospital R1 was sent to, that R1 was being sent to another hospital for inpatient care. V2 said she assumed it was for psychiatric care. V2 said the next morning they were contacted by a forensic nurse at that hospital saying R1 was claiming to have been sexually abused. V2 said records were…
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.
- Potential for harm · Dcited before2024-05-01 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to investigate an allegation of abuse. This applies to one of three residents (R1) reviewed for abuse in the sample of 8. The findings include: The facility face sheet for R1 shows diagnoses to include hypoxic ischemic encephalopathy (type of brain damage caused by a lack of oxygen to the brain), major depression disorder with psychotic features, anxiety, dementia and cardiomyopathy. The brief interview for mental status (BIMS) dated 2/19/24 shows R1 cognitively intact. R1's facility assessment shows her to be able to walk independently. On 4/26/24 at 11:43 AM, V2 Director of Nursing said R1 was taken to the hospital on 4/24/24 after she eloped from the facility and became aggressive with the staff. V2 said the facility was notified from the hospital R1 was sent to, that R1 was being sent to another hospital for inpatient care. V2 said she assumed it was for psychiatric care. V2 said the next morning they were contacted by a forensic nurse at this hospital saying R1 was claiming to have been sexually abused. V2 said records…
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.
- Potential for harm · Ecited before2023-11-02 · tag F0602 — failed to protect residents from theft of their belongings — patternProtect each resident from the wrongful use of the resident's belongings or money.
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 prevent misappropriation of medications for 13 of 13 residents (R1, R2, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14) reviewed for misappropriation in the sample of 17. The findings include: 1) R1's electronic face sheet printed on 11/2/23 showed R1 has diagnoses including but not limited to quadriplegia, intracranial injury with loss of consciousness, epilepsy, chronic pain, and neuralgia and neuritis. R1's facility assessment dated [DATE] showed R1 has severe cognitive impairment. R1's physician's orders dated 2/25/22 showed R1 receives oxycodone 5mg every 6 hours as needed for chronic pain. The facility's narcotic reconciliation records from August 2023-October 2023 for R1's oxycodone 5mg showed V5 (Licensed Practical Nurse-LPN) removed 104 extra doses during her shifts from 6am-6pm. There is no record these medications were administered. 2) R2's electronic face sheet printed on 11/2/23 showed R2 has diagnoses including but not limited 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.
- Potential for harm · Ecited before2023-11-02 · tag F0610 — failed to investigate and act on abuse reports — patternRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a nurse was removed from resident care after an allegation of misappropriation of controlled medications and failed to immediately investigate an allegation of misappropriation of medication. These failures apply to 6 of 13 residents (R1, R6, R8, R10, R12, R13) reviewed for misappropriation in the sample of 17. The findings include: The facility's initial incident report investigation report dated 10/17/23 showed, medication error/diversion. On 11/2/23 at 9:00 AM, V6 (Licensed Practical Nurse) stated, I questioned the medication count a few weeks ago and I didn't look into it, I just noticed that one residents medications (R1) were being ordered more often than I thought he was using. On October 11th, some medication had come in for (R10) and he had 20 Norco tablets come in and I gave him 1 so he had 19 left. The next morning I gave report to (V5-LPN), counted narcotics, and everything was fine. I came back that evening and everything matched but as I did my medication pass, (R10) asked for a Norco and when I pulled…
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.
- Potential for harm · Ecited before2023-11-02 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 identify an excessive amount of narcotic medication usage for 16 residents (R1, R2, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17), failed to ensure an accurate count of narcotic medications for 3 residents (R15, R16, R17), and failed to dispose of a narcotic medication after it was removed from its original packaging for 1 resident (R3). The findings include: 1) The facility's narcotic reconciliation records from August 2023-October 2023 showed V5 (Licensed Practical Nurse) removed the following additional doses of medications: R1's oxycodone 5mg: 104 extra doses, R2's modafinil 200mg: 40 extra doses, R4's oxycodone-acetaminophen 5-325mg: 5 extra doses, R5's oxycodone 5mg: 3 extra doses, R6's Ritalin 5mg: 59 extra doses, R7's oxycodone-acetaminophen 10-325mg: 8 extra doses, R8's Ritalin 5mg: 37 extra doses, R9's Norco 5-325mg: 34 extra doses, R10's hydrocodone-acetaminophen 10-325mg: 76 extra doses, Zolpidem 5mg: 15 extra doses, R11's hydrocodone-acetaminophen 5-325mg: 17 extra doses, R12'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.
- Potential for harm · Fcited before2023-08-17 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 ensure the kitchen was maintained in a clean and sanitary manner, and failed to cover prepared food. This applies to all residents who reside in the facility that consume food prepared in the facility's kitchen. The findings include: The facility Census and Condition of Residents from #672 dated 8/16/23 documents there are 80 resident residing in the facility. The facility provided list of Tube Feed Only (undated) shows 6 residents do not eat food prepared in the facility kitchen. On 8/15/23 at 9:52 AM, the kitchen hoods were greasy with dust adhered to the grease, giving the surface a fuzzy appearance. The hoods are over the cooking areas. The walk in refrigerator had a tray of fruit cups uncovered. The shelves in walk in refrigerator had a black substance speckled over the horizontal and vertical surface that was not in the plastic design of the shelves, but on the surface. This substance could be scraped off. The shelves were in close proximity to the uncovered fruit cups. The same substance was still there…
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.
- Potential for harm · Fcited before2023-08-17 · tag F0925 — failed to control pests — widespreadMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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 control the fly infestation throughout the facility. This applies to all residents who reside in the facility. The findings include: The facility Census and Condition of Residents from #672 dated 8/16/23 documents there are 80 resident residing in the facility. On 08/16/23 at 12:23 PM, R62 was in his room in bed with a fly swatter in his hand. 3 flies were buzzing around him. R62 said, the flies are terrible. R62 said he tries to swat them but more show up. R62's 7/11/23 MDS (Minimum Data Set) shows he has a BIMS (Brief Interview for Mental Status) of 14 showing he is cognitively intact. On 8/17/23 at 10:04 AM, V14 (Wound Care Nurse) was performing wound care on R26. While gathering supplies a fly lands on V14's gloved hand and she blows it off. There were flies on the R26's sheet, arms. and circling the supplies on the overhead table. V14 said, that the flies are a problem because the doors are opening and closing all the time. V14 said, there is a solution but the facility won't do it. V14 said the facility…
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.
- Potential for harm · Ecited before2023-08-17 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a urinary catheter remained below the level of the bladder, failed to ensure the drainage tubing was covered, failed to have a physicians order for a Texas catheter, and failed to provide incontinence care in a manner to prevent cross contamination for a resident with a catheter for 4 of 7 residents (R17, R31, R41, R79) reviewed for urinary catheters in the sample of 22. The findings include: 1. R31's quarterly assessment of 7/3/23 shows he has an indwelling urinary catheter. The 3/11/21 catheter care plan was updated on 7/28/23 to show R31 had a UTI (urinary tract infection). R31's Order summary report of 8/17/23 documents he had orders for Cefepime HCI Injection Solution Reconstituted 1 GM (gram) to be given intramuscularly two times a day for urine culture. And Nitrofurantoin Macrocrystal capsule, one capsule every 6 hours for urine culture. On 8/15/23 at 09:20 AM, R31 was observed lying in bed, his with his urinary drainage bag…
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.
- Potential for harm · D2023-08-17 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
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 ensure the confidentiality of a resident's electronic medical record was protected for 1 of 1 residents (R13) reviewed for privacy and confidentiality in the sample of 22. The findings include: R13's admission Record, printed by the facility on 8/17/23, showed he had diagnoses including unspecified head injury, major depressive disorder, that is severe with psychotic symptoms, and anxiety disorder. R13's facility assessment dated [DATE] showed he was cognitively intact and required extensive assist of staff for bed mobility, transfers, dressing, toileting, personal hygiene and bathing. R13's Order Summary Report, printed by the facility on 8/17/23, showed R13 has orders for medications for major depression and anxiety disorder. On 8/16/23 at 9:55 AM, the medication cart for the A hall, was sitting in the main hall that leads from the A hall to the dining room, activity room, and the other end of the building that the B and C halls were…
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.
- Potential for harm · Dcited before2023-08-17 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure interventions were in place for a resident with skin shearing for one of one resident (R30) reviewed for non-pressure wounds in the sample of 22. The findings include: R30's face sheet printed on 8/17/23 showed diagnoses including but not limited to multiple sclerosis, morbid obesity, and paraplegia. R30's facility assessment dated [DATE] showed moderate cognitive impairment and extensive staff assistance needed for bed mobility. On 8/15/23 at 9:45 AM, R30 was lying in a bariatric size bed and stated he had sores on his buttocks. R30 said they have been for quite a while. A sign was posted on the wall above the bed which stated: Raise knees to avoid sliding down in bed. R30's knees were not raised, and he was low in the bed with his toes touching the foot board. At 11:03 AM, V12 (CNA-Certified Nurse Aide) said R30 will stay in bed today until the wound doctor comes to do the weekly rounds. V12 said R30 has open areas but was unsure…
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.
- Potential for harm · D2023-08-17 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
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 ensure a resident's call light system was in working order for 1 of 1 resident (R68) reviewed for call lights in the sample of 22. The findings include: R68's admission Record, printed by the facility on 8/17/23, showed she had diagnoses including cerebral palsy, epilepsy, gastrostomy (g-tube), major depressive disorder, and dysphagia (difficulty swallowing). R68's facility assessment dated [DATE] showed she is dependent on staff for transfers, bed mobility, dressing, eating, toileting, personal hygiene, and bathing. The assessment showed R68 has a limitation in range of motion to her bilateral upper and lower extremities. The assessment also showed R68 is always incontinent of bowel and bladder. On 8/15/23 at 10:23 AM, R68 was sitting in her wheelchair. A speech tablet was attached to R68's wheelchair, allowing R68 to communicate using the speech tablet. R68 said almost every night she has to wait about 2 hours for her call light to 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.
- Potential for harm · Dcited before2023-08-01 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 prevent a medication error for 1 of 3 residents (R1) reviewed for medication administration in the sample of 5. The findings include: R1's electronic face sheet printed on 8/1/23 showed R1 has diagnoses including but not limited to intracranial injury without loss of consciousness, diabetes type 2, hemiplegia, epilepsy, history of traumatic brain injury, hypertension, and dementia with behaviors. R1's facility assessment dated [DATE] showed R1 has moderate cognitive impairment. R1's nursing care plan dated 7/14/23 showed, (R1) was given the wrong medications which caused pressure in his chest per resident .send to emergency room for evaluation and treatment. The facility's incident report investigation dated 8/1/23 showed, On 7/14/23 at 1950 (7:50 PM), this resident (R1) was administered 1 Norco 5/325mg, nystatin swish and swallow, and trazodone 200mg during evening medication administration. This resident has no known drug allergies.…
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.
“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.
- 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.
Fines & penalties
$12,258 in federal fines across 1 penalty.
- $12,258 — penalty dated 2024-05-01
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| DEMARANVILLE, CONNIE | Individual | CORPORATE DIRECTOR | since 07/01/2008 |
| EYRICH, DAVE | Individual | CORPORATE DIRECTOR | since 06/01/2020 |
| GIBSON, ARTHUR | Individual | CORPORATE DIRECTOR | since 01/01/2004 |
| GUZZARDO, JOHN | Individual | CORPORATE DIRECTOR | since 06/01/1992 |
| HICKS, CRISTE | Individual | CORPORATE DIRECTOR | since 06/10/2021 |
| NANCE, THOMAS | Individual | CORPORATE DIRECTOR | since 07/01/2019 |
| TURNROTH, ERIC | Individual | CORPORATE DIRECTOR | since 08/01/1995 |
| HUIZENGA, SHEILA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/01/2025 |
| JACKSON, ROBIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/01/2025 |
| MATHEW, STANLEY | Individual | ADP OF THE SNF | since 06/02/2022 |
CMS files one row per role, so the 12 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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.
About 89% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
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
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
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.
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 145556. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-23, 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.