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Robinson Rehab And Nursing

600 East Robinwood Drive, Robinson, IL 62454 · For profit - Partnership · 67 certified beds · (618) 544-3192 Medicare & Medicaid certified

Call the home — (618) 544-3192 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jun 20262 actual-harm citations1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$14,015 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2026
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $14,015 in federal fines (most recent 2025-09-03)
  • its payroll-based staffing rating is low (2/5)
  • about 21% of its spending goes to commonly-owned related companies

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1404 E Main St · (618) 544-8333 · Call to confirm hours
Pharmacy
1300 N Allen St · (618) 544-2167 · Call to confirm hours
Grocery
1404 E Main St · (618) 544-9486 · Call to confirm hours
Park
400 W Condit St · (618) 544-2350 · Typically dawn to dusk
Place of worship
11157 N Trimble Rd · (618) 544-3313

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased17.1%13.4%15.4%worse
Long-stay residents who lose too much weight19.2%6.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.6%0.9%0.9%better
Long-stay residents with a urinary tract infection2.3%1.5%2.0%worse
Long-stay residents with depressive symptoms9.3%54.2%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.9%3.1%3.3%worse
Long-stay residents whose ability to walk worsened17.5%14.3%16.1%typical
Long-stay residents on antianxiety or hypnotic medication16.0%18.3%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%91.8%95.3%typical
Long-stay residents with pressure ulcers5.2%4.8%4.7%worse
Long-stay residents with worsening bladder/bowel control17.8%20.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table9.9%21.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%2.2%1.4%better
Short-stay residents given the seasonal flu vaccine97.3%63.1%79.4%better
Short-stay residents rehospitalized after admission32.2%26.1%22.6%worse
Short-stay residents with an outpatient ER visit21.7%13.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.402.021.67better
Long-stay outpatient ER visits per 1,000 resident days3.222.221.80worse

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

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

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

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

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

46.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 89 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

46.7%U.S. median 51.5%
Got home and stayed home
13.7%U.S. median 10.7%
Went back to hospital
57.1%U.S. median 56.6%
Met the expected recovery
0.40U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.23hours / resident / day
Occupational therapy
0.09hours / resident / day
Speech therapy

Met the expected recovery: 57.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 21 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.40 therapist hours per resident per day in 2026Q1 — more than 69% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF46.7%CMS range 33.8–55.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF13.7%CMS range 9.4–18.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge57.1%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge38.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge42.9%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified90.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.4%CMS range 3.3–12.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.311.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.77
RN hours/ resident / day
0.59
LPN hours/ resident / day
2.15
Aide hours/ resident / day
3.51
Total nurse hours/ resident / day
0.55
RN hoursweekends
47.6%
Total nursing turnover
56.3%
RN turnover

How full it usually is: this home is certified for 67 beds and averages 62.5 residents a day — about 93% occupied, or roughly 4 beds typically open. It runs fairly full. 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 3.51 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.77 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.15 is below 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 3.01 hrs/resident/day on weekends vs 3.72 on weekdays — 19% thinner on weekends. RN hours go from 0.86 to 0.55 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 48% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

2
deficiencies at the latest standard inspection (2025-11-21)
5
at the previous standard inspection (2024-08-16)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

22 citations, most serious first. The 13 most serious are shown; the remaining 9 are one tap away and print in full.

  • Actual harm · Gcited before2025-09-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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, observation, and record review the facility failed to provide supervision and implement effective interventions to prevent falls for 1 (R1) of 3 residents reviewed for falls in the sample of 12. This failure resulted in R1 sustaining a fall that caused a fracture of left knee and large hematoma of scalp and a right parietal subarachnoid hemorrhage. This past non-compliance occurred on from [DATE] to [DATE].Findings Include:R1's face sheet documents an original admission date of [DATE]. R1 has diagnoses in her electronic health record including, but not limited to dementia, dorsalgia, history of falling, abnormalities of gait and mobility, unsteadiness on feet, muscle weakness, and difficulty in walking.R1's non-medication related physician orders include but are not limited to order dated [DATE] for monitoring and prevention of adverse effects of opioid medications including, but not limited to falls, disorientation, dizziness, vertigo, and lightheadedness.R1's most recent minimum data set…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Actual harm · Gcited before2025-09-03 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor 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 interview and record review, the facility failed to respond to residents' requests for assistance in a timely manner to promote dignity and respect for 1 (R1) of 4 residents reviewed for call light response in the sample of 4. This failure resulted in R1 having to urinate on herself, causing her feelings of discomfort, anxiety, humiliation, and embarrassment.Findings Include: R1's admission Record documented an admission date of 4/27/25 and included diagnoses of morbid (severe) obesity due to excess calories, spinal stenosis, need for assistance with personal care, presence of right artificial hip joint, pain in right hip, presence of artificial knee joint, bilateral, essential tremor, anxiety, and muscle weakness. R1's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 is cognitively intact. This MDS also documents under Functional Abilities and Goals, R1 is dependent for toileting hygiene, shower/bathe self, upper body…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-03-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 implement progressive person centered interventions for fall prevention for 1 (R1) of 3 residents reviewed for falls in the sample of 3. This failure resulted in R1 experiencing 4 falls between 2/20/24 and 3/3/24 which required emergency room evaluation and/or treatment for injuries that included skin tears to right arm, a right orbital fracture, head lacerations, and baseball size hematoma to the head. Findings Include: R1's admission Record documented an initial admission date to the facility as 9/22/23. R1 is documented on this same record as being [AGE] years old with diagnoses including but not limited to: Unspecified Dementia, unspecified severity, with agitation; Type 2 Diabetes Mellitus; Major Depressive Disorder; Insomnia; Muscle Weakness; and Cognitive Communication Deficit. V9 (Physician) is documented as being R1's Primary Care Physician. R1 was observed as being alert to person only during this survey. Review of R1's Progress…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-17 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 provide increased staff supervision in order to protect a resident from resident-to-resident abuse for one (R2) of three residents reviewed for abuse in the sample of three. This failure resulted in R1 threatening, hitting and throwing water on R2, and with R2, upon staff directives, curtailing his normal activities to try to avoid R1.Findings include:R2's admission Record documented an admission Date of 12/14/25 and listed Diagnoses including Diabetes Type 2 and Depression. A Minimum Data Set, dated [DATE] documented that R2 had a BIMS (Brief Interview for Mental Status) score of a 12, indicating R2 had moderately impaired cognition.R2's Care Plan dated 5/24/26 documented a problem area, I prefer to help with small chores. I helped my mother and sister for several years. I like to help to give myself a purpose, with a corresponding intervention, I understand that I am only to assist my mom (who is a resident) by pushing her wheelchair and not other…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-17 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to report resident-to-resident physical abuse to local law enforcement for one resident (R2) of three residents reviewed for abuse in the sample of three. Findings include:An IDPH (Illinois Department of Public Health) Long Term Care Serious Injury Incident and Communicable Disease Report dated 5/24/26 documented, Incident date: 5/24/26 at 7:00pm. Location: Common/Dining area. Detailed incident summary: (R1) and (R2) were in the dining/common area of the facility. (R1) was in his wheelchair and (R2) attempted to 'move' him a little. (R1) swung at (R2) and struck (R2) open handed on the jaw. Staff witnessed the incident and immediately de escalated and separated the two residents. Nursing staff completed an injury assessment on both individuals, there were no visible or serious injuries or trauma noted. No further incident occurred. Immediate interventions and safety actions: 1. Individuals were immediately separated. 2. Staff remained with both residents to ensure de escalation. 3. Residents had increased monitoring to ensure…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-17 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to identify and thoroughly investigate allegations of resident-to-resident abuse and failed to ensure residents were not at risk for further abuse for one resident (R2) of three residents reviewed for abuse in the sample of three. Findings include:R2's admission Record documented an admission Date of 12/14/25 and listed Diagnoses including Diabetes Type 2 and Depression. A Minimum Data Set, dated [DATE] documented that R2 had a BIMS (Brief Interview for Mental Status) score of a 12, indication R2 had moderately impaired cognition. R2's Care Plan dated 5/24/26 documented a problem area, I prefer to help with small chores. I helped my mother and sister for several years. I like to help to give myself a purpose, with a corresponding intervention, I understand that I am only to assist my mom (who is a resident) by pushing her wheelchair and not other residents in this facility, and problem area, I currently have an alteration to my ability to care for self…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-11-21 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to ensure that the dish machine and 3 compartment sink were effectively sanitizing the dishes and stationary equipment. This has the potential to affect all 59 residents residing in the facility.The Findings Include: During the initial tour of the kitchen on 11/18/25 at 9:45am, V4 (Cook) measured the sanitizer levels of dish machine with a quaternary sanitizer test strip. The strip measured 0 part per million (ppm). V4 then retrieved chlorine test strips and tested the dish machine again with a 0 ppm reading. A bucket of sanitizer was then tested with the quaternary test strip and a 0 ppm reading was obtained. A dishwasher Temperature Log and Temp/Chemical Sanitizing Machine dated November 2025 was provided and was filled out through the current day 11/18/2025. The log documented that the sanitizer level for the dish machine should be 50 ppm chlorine. This log documented that the sanitizer level was checked for the breakfast shift and V4 (Cook) stated that she was the employee to fill out the log for the breakfast…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-11-21 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to follow policy and procedure for infection control practices for 4 of 16 residents (R13, R54, R57, and R59) reviewed for infection control in the sample of 35. The Findings Include:1. R54's admission Record documented an Initial admission Date of 11/12/2024. R54's admission Record documents the following diagnoses: Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side, polyosteoarthritis, neuromuscular dysfunction of bladder, pain in right knee, major depressive disorder, hypotension, and acute kidney failure. R54's Order Summary Report dated 11/20/2025 documented an order for suprapubic catheter change monthly on the 7th - urologist to change. The order summary goes on to document an order for infection precautions - enhanced barrier - staff will wear gown and gloves when in direct resident contact.R57's admission Record documented an Initial admission Date of 10/23/2025. R57's admission Record documents the following diagnoses: unspecified fracture of third lumbar vertebra,…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-09-03 · tag F0725 — failed to have enough nursing staff — widespread
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    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 sufficient staff were scheduled/available to provide timely care to meet residents' needs. This failure has the potential to affect all 60 residents residing in the facility. Findings Include:1. R1's admission Record documented an admission date of 4/27/25 and included diagnoses of morbid (severe) obesity due to excess calories, spinal stenosis, need for assistance with personal care, presence of right artificial hip joint, pain in right hip, presence of artificial knee joint, bilateral, essential tremor, anxiety, and muscle weakness. R1's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 is cognitively intact. This MDS also documented under Functional Goals and Abilities R1 is dependent for toileting hygiene, shower/bathe self, upper body dressing, and putting on/taking off footwear.R1's current Care Plan included a focus area of I currently have an alteration to my…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-07-02 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    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 maintain air conditioning equipment and provide comfortable temperatures for 21 of 21 residents (R1-R21) reviewed for environment in the sample of 21. Findings Include: On 06/27/2025 at 11:30 A.M. while entering the building fans were observed in resident rooms, and lights were off in the dining room. On 06/27/2025 at 11:56 A.M. V1 (Administrator) stated that there was a recent problem with the air, but it was fixed yesterday 06/26/2025. On 06/27/2025 at 1:12 P.M. V3 (Agency Registered Nurse) stated that it is cooler in the facility. V3 stated that it was hot in the building but not unbearable. V3 stated there were fans in the hallway blowing air. V3 stated she is not aware of any residents that had heat related issues. On 06/27/2025 at 1:20 P.M. R3 stated that it has been miserable with the temperatures in the building. R3 stated she has two fans and is uncomfortable, but she was sure that everyone else is too. R3 stated that she did not…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-16 · tag F0638 — pattern
    Assure that each resident’s assessment is updated at least once every 3 months.
    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 quarterly assessments were completed within the required time frames for nine (R13, R16, R25, R27, R47, R48, R49, R52 and R54) of nine residents reviewed for quarterly assessments in a sample of 35. The Findings Include: R13's Face Sheet documented an admission date of 1/13/23. R13's most recent completed and submitted quarterly Minimum Data Set (MDS) Section A documented an Assessment Reference Date (ARD) of 4/27/24. The next quarterly MDS Section A was initiated with an ARD of 7/28/24 but had not been completed or submitted as of the date of this review on 08/16/24. This indicates more than 92 days between completion of assessments and shows R13's quarterly assessment had not been completed/submitted within 14 days after the ARD of 7/28/24. R16's Face Sheet documented an admission date of 10/12/22. R16's most recent completed and submitted quarterly MDS Section A documented an ARD of 4/16/24. The next quarterly MDS Section A was initiated with an ARD of 7/5/24 but had not been completed or submitted as of the date…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-16 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    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 comprehensive assessments were completed in accordance with required time frames for two (R12, R44) of two residents reviewed for comprehensive assessments and timing in the sample of 35. The Findings Include: R12's Face Sheet documented an admission date of 7/29/22. R12's previous Comprehensive Minimum Data Set (MDS) assessment documented an Assessment Reference Date (ARD) of 7/4/23. R12's most recent completed and submitted Quarterly MDS assessment, Section A documented an Assessment Reference Date (ARD) of 4/7/24. R12's current Comprehensive MDS assessment Section A documented it had been initiated with an ARD of 7/2/24 but documents no completion date as of the date of this review on 08/16/24. This indicates more than 92 days between quarterly completion of assessments, more than 366 days between completion of comprehensive assessments, and shows R12's comprehensive assessment had not been completed/submitted within 14 days after the ARD of 7/2/24. R44's Face Sheet documented an admission date of 8/30/22. R44'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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-16 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    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 therapeutic diets as ordered for 1 (R47) of 2 residents reviewed for dietary supplements in the sample of 35. Findings Include: R47's Face Sheet documented an admission date of 11/13/23 and included the following diagnoses of unspecified protein-calorie malnutrition, dysphagia, oropharyngeal phase. R47's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. This same MDS documents under section I Active Diagnoses, a diagnosis of I5600 Malnutrition (protein, calorie) risk of malnutrition. R47's Physician Order Summary dated 5/13/2024 documented high protein pudding. On 8/13/2024 at 12:05 PM, R47 was sitting with V9 (Speech Language Pathologist/SLP) being served a regular mechanical diet of ground pulled pork with gravy, creamed corn, baked beans-no bacon, soft chopped fruit, and cornbread/margarine. R47's meal tray did not include high protein…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 9 citations
  • Potential for harm · D2024-08-16 · tag F0810 — isolated
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    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 adaptive utensils for one (R21) of one resident reviewed for assistive devices in the sample of 35. Findings include: R21's Face Sheet documented an admission date of 7/8/23 and includes the following diagnoses encephalopathy, unspecified, hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non-dominant side, cerebral infarction due to unspecified occlusion or stenosis of other cerebral artery, and dysphagia, oropharyngeal phase. R21's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. This same MDS documents under section K0100-Swallowing Disorder, C. coughing or choking during meals or when swallowing medications. R21's Physicians Orders dated 8/14/2024 documented an order for, Low Concentrated Sweets, diet, dysphagia mechanical texture, regular/thin consistency (No bread, toast, buns, pancakes, french…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-16 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain aseptic technique while performing urinary catheter care and implement transmission based precautions for two (R23, R47) of two residents reviewed for infection control in a sample of 35. Findings include: 1. R23's Face Sheet documented an admission date of 8/13/22. R23's Face Sheet included the following diagnoses: multiple sclerosis, neuromuscular dysfunction of bladder, unspecified, dementia, unspecified, cerebral infarction due to embolism of left middle cerebral artery. R23's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 3, indicating R23 had severe cognitive impairment. This same MDS documents under section H0100, Appliances yes for an indwelling catheter. R23's Physician Order Sheet (POS) documented an order dated 12/24/2022 Foley Catheter Care every shift. R23's Care Plan documented a focus area of an indwelling catheter related to neurogenic bladder with interventions 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-10-20 · tag F0919 — failed to provide a working call system — widespread
    Make 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

    Based on observation, interview, and record review the facility failed ensure a functioning or equivalent notification call system was available for resident use. This failure has the potential to effect all 60 residents residing in the facility. Findings Include: On 10/17/23 at 10:00 AM, V1 (Administrator) stated that the electronic call light system is not working. V1 stated after ordering new parts which failed to correct the problem, a whole new call light system has been ordered. The current plan is that they are telling residents to ring their hand bell, along with using the call light. V1 stated that the call light system will light up, but it doesn't make a sound. Residents are told to use both the call light and the bell, or just the bell. The staff then go down the hall to find who's bell it is, and if they use the call light it helps them respond quicker. The system will take a couple weeks to install once it comes in. There is not a definite date on when this will occur due to waiting on the system to be delivered. 1. On 10/19/23 at 10:35 AM, R3 was observed lying in…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-20 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor 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

    Based on interview and record review the facility failed to provide timely staff response to call lights for five residents of five residents (R12, R40, R45, R46, R53) reviewed for call lights in the sample of 34. Findings include: 1. On 10/17/23 at 10:48 am, R45, who is alert and oriented, stated call lights take a long time, too long, but could not indicate how long. R45's Face Sheet documented an admission date of 4/17/23 and diagnoses including Hemiplegia and Hemiparesis of the Right Dominant Side and Epilepsy. 2. On 10/18/23 at 9:45 am, R46 was alert and oriented. R46 stated call lights often take up to 40 minutes to be answered. R46's Face Sheet documented an admission date of 7/21/23 and diagnoses including Polyneuropathy, Hypertension, Chronic Pain, and Chronic Non Pressure Ulcers of the Lower Extremities. 3. On 10/17/23 at 12:53 pm, V5 (family member of R53) was observed ambulating R53 out of the bathroom. R53 was alert but oriented only to self. V5 stated she had been trying for 45 minutes to get staff to help her take R53 to the bathroom, but, They kept saying they would…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-20 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of 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 record review, observation and interview the facility failed to ensure that call bells are placed within reach of residents for 2 of 15 residents (R3 and R25) reviewed for call lights in a sample of 34. The Findings Include: 1. R25's admission record documents an admission date of 1/27/20. This record also lists medical diagnosis that include: paralytic gait, anxiety disorder, contracture of the left and right hand and hemiplegia and hemiparesis following a cerebral infarction affecting right dominant side. R25's Quarterly Minimum Data Set, dated [DATE] documents that R25's Brief Interview for Mental Status score is a 9 indicating he has a moderate impairment of cognition. This same document in Section G indicates that R25 requires extensive assistance of two persons for: bed mobility, transfers, toilet use, persona hygiene, and dressing. On 10/17/23 at 10:30 AM, R25 was observed in bed watching television and his call bell was over on a bedside dresser not within reach. When asked how he notifies staff…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-20 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview the facility failed to update the comprehensive care plan with new focus areas and interventions for 1 of 15 residents (R47) reviewed for care plans in a sample of 34. The Findings Include: R47's admission record documents an admission date of 1/23/23. This same document includes the following diagnosis: Alzheimer disease, anxiety, and depression. On 9/24/23 a dietary recommendation note for R47 written by V6 (Registered Dietitian) documents r/t (related to) wt (weight loss) and current intakes , rec (recommend) mighty shakes bid (twice daily). R47's current physician order sheet has an order for mighty shakes with meals twice a day with a start date of 9/25/23. On 10/19/23 at 12:30 PM, V4 (Minimum Data Set Coordinator/Care Plan Coordinator) verified that R47's weight loss and mighty shake were not on the comprehensive care plan and stated that she will speak with the Dietary Manager to see about updating the care plan to ensure all problem areas are included. The Comprehensive Care Plan Policy dated 6/25/20 states that an individualized…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-20 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a residents medication regimen was free from unnecessary medications for one of five residents (R33) reviewed for unnecessary medications in the sample of 34. Findings include: R33's Face Sheet documented an admission date of 11/19/22 and diagnoses including Alzheimer's Dementia and Unspecified Psychosis. R33's Physicians Orders documented an order for Risperdal 0.25mg (milligrams) one tablet at bedtime with a start date of 9/11/23. R33's Psychopharmacological Medication Flow Sheet documented an entry dated 6/23/21,Risperdal 0.5mg give one at bedtime, and the next entry dated 9/11/23, (decrease) Risperdal to 0.25mg. at bedtime. A 9/11/23 Medication Review Request documented,Risperdal 0.5mg Can we possibly do a GDR (Gradual Dose Reduction) or place her on a different medication?, with the Physicians response,Decrease Risperdal to 0.25mg. daily. There was no documentation in R33's chart to indicate a GDR was attempted between 6/23/21 and 9/11/23. On 10/20/23 at 09:32 am, V2 (Director of Nurses) confirmed that R33 did…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-20 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure residents were free from significant medication errors for two of 14 residents (R33, R47) reviewed for medication errors in the sample of 34. Findings include: 1. R33's Face Sheet documented an admission date of 6/8/21 and diagnoses including Cerebral Infarction, Unspecified Psychosis, Alzheimer's Dementia, and Hypertension. R33's Physicians Orders documented an order for Trazodone 50 mg (milligrams) one tablet twice daily with a start date of 9/11/23. R33's Medication Administration Record for September and October 2023 indicated R33 was receiving Trazodone 50mg one tablet twice daily. A Medication Review Request dated 9/11/23 and signed by R33's Physician documented, Increase Trazodone to 50mg one half tablet twice daily, (diagnosis), Other Depressive Episodes. On 10/20/23 at 09:32 am, V2, Director of Nurses, acknowledged the 9/11/23 medication order for R33 had been incorrectly entered into the medical record. V2 stated she would call R33's Physician immediately to report the error and obtain further…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-20 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure 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 store controlled medications under double locks per current standards of practice for 1 of 4 residents (R29) reviewed for controlled medication storage in the sample of 34. Findings Include: On 10/20/23 at 9:47 AM, observation of the locked medication storage room with V3 (Licensed Practical Nurse) present revealed a refrigerator labeled for medication storage only. This refrigerator was not observed as being locked. Present inside the refrigerator was an open bottle of Lorazepam oral concentrate 2 milligrams / milliliter labeled for R29. V3 confirms that this refrigerator is not kept locked, although the Lorazepam is acknowledged to be stored in this refrigerator. Other medications such as insulin and vaccinations were also noted to be stored in this refrigerator. On 10/20/23 at 10:41 AM, V2 (Director of Nursing), confirms that Lorazepam is a controlled medication and despite receiving conflicting information from their pharmacy, should be kept under a double lock system. V2 stated that nursing staff have…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$14,015 in federal fines across 1 penalty.

  • $14,015 — penalty dated 2025-09-03

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.

Part of a chain

This home belongs to STERN CONSULTANTS — 22 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.5+0.5 vs chain
Health inspection 3 of 52.4+0.6 vs chain
Staffing 2 of 52.2-0.2 vs chain
Quality measures 3 of 53.8-0.8 vs chain
The other 21 homes this chain runs (chain average 2.5★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleSince
ETN FAMILY HOLDINGS LLCOrganizationDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2022
ERBLICH, AVRAHAMIndividualDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2022
FRIEDMAN, BENJAMINIndividualDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2022
MILLMAN, CHAIMIndividualDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2022
NEWHOUSE, ERICIndividualDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 02/01/2022
SHEPS, BORUCHIndividualDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2022
STERN, BEZALELIndividualDIRECT OWNERSHIP INTERESTsince 02/01/2022
E NEWHOUSE FAMILY TRUSTOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 02/01/2022
T NEWHOUSE FAMILY TRUSTOrganizationINDIRECT OWNERSHIP INTEREST; TRUSTEE OF THE SNF; ADP OF THE SNFsince 02/01/2022
STERN THERAPY CONSULTANTS LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2022
MATHEW, STANLEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2025
MCGILL, JAMESIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2022
PLEW, ANDREAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2022
SWEDENBURG, JANIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/30/2024
NEWHOUSE, TEMIIndividualTRUSTEE OF THE SNFsince 02/01/2022
ROBINSON PROPCO LLCOrganizationADP OF THE SNFsince 02/01/2022
SACKTON, AVRAHAMIndividualADP OF THE SNFsince 02/01/2022

CMS files one row per role, so the 41 rows in the source record cover these 17 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.

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

Follow the money — this home’s finances

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

$7.0M
Net patient revenuemost recent cost report
+11.2%
Operating marginrevenue minus expenses
$1.3M
Related-party expense21% of expenses
Who pays — share of resident-days
Medicaid 57%Medicare 18%Other / private 25%

This home reported $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 21% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. 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

$293per resident / day
operating cost
$8,918per month
≈ monthly operating cost
$330per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in IL

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145760. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-21, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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