The Citadel at Saint Anne Place

Location & what’s nearby

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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

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.

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.

45.4% 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 186 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 46.9% 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 113 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 0.28 therapist hours per resident per day in 2026Q1 — more than 43% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% 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.

Staffing

How full it usually is: this home is certified for 179 beds and averages 125.4 residents a day — about 70% occupied, or roughly 54 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 3.42 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.85 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.78 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 2.94 hrs/resident/day on weekends vs 3.62 on weekdays — 19% thinner on weekends. RN hours go from 0.97 to 0.57 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 62% is well above 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.

44 citations, most serious first. The 19 most serious are shown; the remaining 25 are one tap away and print in full.

• Actual harm · Gcited before2025-11-25 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed ensure a thorough assessment was performed for a resident sustaining a fall and failed to identify an acute fracture prior to sustaining a second fall. This failure resulted in R3 sustaining a fall with x-ray results showing a right hip impacted subcapital fracture of right femoral neck without staff identifying and reporting her injury and sustaining a 2nd fall approximately two days later delaying emergency care and services. This applies to 1 of 3 residents (R3) reviewed for quality of care in the sample size 18. The findings include: R3's face sheet shows diagnoses including Alzheimer's, unspecified intracapsular fracture of right femur, subsequent encounter for closed fracture with routine healing, unspecified fracture of left pubis, palliative care, anxiety, muscle weakness, unsteadiness on feet, repeated falls and hypertension. R3's Fall Risk assessment dated [DATE] shows she is high risk for falls. R3's Final Incident Report dated 10/10/25 shows on…

  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
• Actual harm · Gcited before2025-07-08 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to assess, document, notify the provider, and monitor an injury of unknown origin for 1 of 3 residents (R1) reviewed for quality of care in the sample of 5. This failure resulted in R1 exhibiting signs of an injury (bruising, pain with movement of left arm) for three days before the facility notified the provider and obtained an order for an X-ray. R1's X-ray showed a non-displaced fracture of her left humerus (upper arm). The findings include: On 7/3/25 at 11:01 AM, R1 was seated in a padded, reclining wheelchair. R1 had a sling to her left arm. V5 (Unit Manager) explained to R1 that we needed to look at her arm. V5 unhooked R1's sling, removed her left arm from the sling, and exposed the skin to R1's upper arm. R1 had yellow bruising noted to her entire left upper arm, from her shoulder down to her elbow. R1 was unable to tell the surveyor what happened to her arm. The surveyor asked if R1's arm hurt and she replied, Only hurts when you…

  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
• Actual harm · Gcited before2025-06-05 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide 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 4. R117's face sheet documents she was admitted to the facility on [DATE] with multiple diagnoses including the presence of a stage 3 pressure ulcer to the left buttock, a stage 4 pressure ulcer to the left lower back, stage 3 pressure ulcer to the sacral region, and stage 3 pressure ulcers to the right upper back and left lower back. On 6/4/25 at 10:25 AM, R117 was lying in her bed with an air mattress, and she was positioned onto her right side with pillows. The skin evaluation forms were requested and reviewed and show the first pressure ulcer assessments were completed on 5/8/25. On 6/5/25 at 9:24 AM, V10 RN, said when a resident is admitted with pressure injuries it is the responsibility of the admitting nurse to perform wound assessments and document them in the wound sheets. She said this should be done on the day of admission. After the initial assessment the resident is placed on wound rounds and will be seen by the wound physician and V6. She said the initial assessment should include the measurements…

  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
• Actual harm · Gcited before2025-06-05 · 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 assist a resident at risk for falls with reaching his urinal (R58), and safely transferring a resident with a mechanical lift (R23 and R2). This failure resulted in R58 falling and obtaining a fractured hip and wrist requiring surgery and hospital stay. The applies to three of eleven residents reviewed for safety in the sample of 59. The findings include: 1. The facility face sheet shows R58 was admitted to the facility with diagnoses to include adult failure to thrive, Type 2 Diabetes Mellitus, chronic kidney disease and low back pain. R58's facility assessment dated [DATE] shows he has no cognitive impairment and required maximum assist from staff for standing and toileting. On 6/04/25 at 2:18 PM, R58 said he was standing up at the foot of his bed reaching for his urinal. R58 said his legs gave out and he fell. R58 said he had his call light on because he could not reach his urinal. R58 said after half an hour he tried to do it himself…

  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
• Actual harm · Gcited before2025-06-05 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure accurate weights were obtained, failed to ensure significant weight loss was identified and reported to the dietitian, and failed to implement dietitian recommendations for 4 of 6 residents (R28, R3, R55, R41) reviewed for nutrition in the sample of 59. This failure resulted in R28 experiencing significant weight loss without the Registered Dietitian being notified. The findings include: 1. R28's face sheet showed he was admitted to the facility 9/21/22 with diagnoses to include anemia, hypertension, atrial fibrillation, primary osteoarthritis of left knee, primary osteoarthritis of left hip, and pressure ulcer of right ankle. R28's care plan initiated 10/3/22 showed, Risk for impaired skin integrity due to incontinence and decreased functional mobility . Approaches: . Nutritional support based on assessment and MD (physician) orders . R28's care plan initiated 9/28/22 showed, [R28] has increased potential for weight changes related…

  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
• Actual harm · Gcited before2024-08-07 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide 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 assess and notify the wound care physician with changes in a pressure injury, and failed to implement pressure relieving intervention to prevent a pressure injury. This applies to 2 of 8 residents (R95 & R100) reviewed for pressure injuries in the sample of 23. These failures resulted in R100's pressure injury deteriorating to an unstageable pressure injury. The findings include: 1. R100's face sheet lists his diagnoses to include: nondisplaced intertrochanter fracture (hip fracture), type I diabetes mellitus, and coronary heart disease. R100's wound assessment report, dated 7/3/24 shows a newly identified stage 1 pressure ulcer was found on his right heel. The pressure ulcer measured 7.00 cm (centimeters) X 5.00 cm. R100's care plan, with problem onset of 7/10/24, shows, Problem/Need: Pressure ulcer stage 2 to right bottom heel. Approaches: Measure wound at least weekly. Record HxWxL (height x width x length), appearance, amount and odor…

  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
• Actual harm · Gcited before2024-02-21 · 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 ensure a resident was supervised in preparation for a mechanical lift transfer resulting in a fall with injury, and failed to ensure nonslip material was in place in a wheelchair for 2 of 3 residents (R1, R3) reviewed for safety and supervision in the sample of 5. This failure resulted in R3 receiving an acute subdural hematoma along with 2 lacerations with 8 sutures to the left forehead and R1 receiving 14 sutures to the left forehead. The findings include: 1. R3's [DATE] fall risk assessment showed a moderate risk of falls. R3's [DATE] facility assessment showed severe cognitive impairment. R3's care plan showed he was alert but with memory deficits and impaired decision making. R3's activity of daily living (ADL) care plan showed he required staff assistance for all ADL's. R3's transfer care plan showed he was unable to transfer independently. R3's fall care plan showed he was severely cognitively impaired, was a high risk for falls, 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-11-15 · 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 and record review, the facility failed to provide a safe transfer for a resident. This failure resulted in R1 being transferred without a stand lift device and sustaining a spiral fracture to her right tibia and fibula. This applies to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 8. The findings include: The Diagnosis/History Report, dated 11/14/23, showed diagnoses including iron deficiency anemia, hypothyroidism, atrial fibrillation, congestive heart disease, chronic obstructive pulmonary disease, cellulitis of left lower limb, neuralgia, neuritis, contusion of left lower leg, and transient ischemic attack. R1's Minimum Data Set, dated [DATE], showed she needs substantial/maximal assistance for transfers. R1's Care Plan Card, dated 6/28/23, showed she was to be transferred with a stand lift and two people. The Facility Reported Incident, dated 11/8/23, showed R1 was observed with swelling and tenderness to her right lower extremity on 11/7/23 at 12:30 PM. The…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-07-13 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based observation, interview, and record review, the facility failed to monitor a resident's weight who was experiencing weight loss, and failed to provide the ordered follow-up consults with the Dietician. This applies to one of one resident (R95) reviewed for weight loss in the sample of 23. These failures resulted in R95 experiencing a 15% weight loss. The findings include: The facility face sheet shows R95 was admitted to the facility on [DATE], with diagnoses to include congestive heart failure, repair of left hip fracture, and chronic kidney disease. The facility assessment, dated 5/25/23 for R95, shows her to cognitively intact and requires extensive staff assistance for bed mobility and transfers. The facility care plan for R95 shows on 5/25/23 a problem for weight loss/appetite was added to her care plan with a goal to maintain her current weight and her skin to remain free from pressure wounds. (R95 has a stage 3 pressure wound). Interventions include to weigh the resident as ordered and to record the…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-06-23 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide 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 ensure a dependent resident was provided with incontinence care for 2 of 3 residents (R1, R2) reviewed for incontinence care in the sample of 6. The findings include:1. R1's face sheet showed she was admitted to the facility 6/3/26 with diagnoses to include acute respiratory failure with hypercapnia, spondylopathy in lumbar region, depression, chronic congestive heart failure, lupus erythematosus, and rheumatoid arthritis. R1's facility assessment dated [DATE] showed she has no cognitive impairment. R1's 6/20/26 Daily Skilled Nursing Note showed, . Resident Orientation: Person, Place, Time, Situation, Makes Self Understood without concern. Resident is incontinent of urine. Resident is incontinent of bowel.On 6/23/26 at 9:14 AM, R1 was sitting in her wheelchair. R1 said the first week she was at the facility she woke up at 4:45 AM and was soaked with urine through her nightgown, sheets, and bedding. R1 said her call light had fallen on the floor so she…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-04-21 · tag F0576 — isolated
  Ensure residents have reasonable access to and privacy in their use of communication methods.
  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 protect a resident's rights to receive unopened personal package to 1 of 3 residents (R1) reviewed for resident's rights in the sample of 3.The findings include:R1 facility assessment dated [DATE] shows R1 has a no cognitive impairment.On 4/21/26 at 9 AM, R1 said her packages have been delivered to her already open without her consent. R1 said this had caused her concern and discomfort. R1 said she did not want her packages opened by anyone but herself. R1 said she had been told it was V2 (Director of Nursing-DON) that had been opening her package before delivery. On 4/21/26 at 12:32 PM V9 (Receptionist Staff) said all mail (letters and packages) were delivered to the reception area at different times. The mail and packages were sorted according to residents' room number, then they were to be picked up by Life enrichment staff to be delivered to the resident's room unopened. If mail comes during off hours (when working PMs) mail will be delivered 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-14 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide 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 administer and accurately document administering a lidocaine patch. This applies to 1 of 3 residents (R1) reviewed for medication administration in the sample of 5. The findings include: R1's Order Summary Report dated 4/14/26 shows R1 has an active order for lidocaine external patch 4 % (percent) (Lidocaine) with instructions to apply to the lower back topically one time per day for low back pain. R1's Medication Administration Record (MAR) for March 2026 shows R1's lidocaine patch was administered every day for March except for 3/10/26 and 3/27/26 when R1 refused. R1's MAR for April 2026 shows R1's lidocaine patch was administered every day from 4/2/26 to 4/14/26 and refused the patch on 4/1/26. R1's April and March MAR show R1's pain was well managed. R1's Minimum Data Set, dated [DATE] shows R1 is cognitively intact. On 4/14/26 at 12:15 PM, R1 was lying in bed with her needs met and no noticeable pain. R1 said she cannot recall 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-16 · 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

  Based on interview and record review the facility failed to transfer a resident in a safe manner for 1 of 3 residents (R1) reviewed for falls in the sample of 3.The findings include:R1's electronic face sheet shows R1 has diagnoses of right lower leg wound, dementia, stroke and history of transient ischemic attack.R1's care plan dated 12/2/25 stated (R1) has an ADL self-care performance deficit r/t Dementia and weakness, TOILET USE: R1 is dependent with 2 staff for toileting.A progress notes dated 12/10/25 documents: 1445-CNA came out to patients' room to let this nurse know that patient was on the floor in her bathroom CNA and another nurse went to assist patient, and patient was put back in her wheelchair.On 12/16/25 at 10:53 AM V8 (License Practical Nurse-LPN) said she was R1's Nurse working last 12/10/25 when she saw V7 (Certified Nursing Assistant-CNA) coming from R1's room. R1 was on the floor. V8 said by the time she got to R1's room, R1 was already back in her wheelchair.On 12/16/25 at 11:05 AM, V7 said she was the CNA working when the incident happened. V7 said she placed…

  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 · Ecited before2025-11-25 · 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 ensure residents were treated with dignity by answering call lights in a timely manner. This applies to 4 of 4 residents (R15, R16, R17, R18) reviewed for dignity in the sample of 18. The findings include: On 11/25/25 at 11:30 AM R15 stated, It takes a long time, but I do not know how long because I do not have a clock. It feels like at least 20 - 30 minutes most of the time. It is worse during shift change or when they are on their breaks. I lay in wet diapers quite a while- all the time. They often come in and turn the light off and say they will be back and sometimes they come back and sometimes they don't. It is not good. Some are very nice and others are not. Some do not want to listen to what I want them to do. One girl yesterday threatened to leave the room and not come back.On 11/25/25 at 11:40AM R16 stated, Sometimes an hour- usually a little less. Sometimes I wet my pants because I have to wait so long. Makes me feel helpless. Nighttime I think is the worst. Some of the staff are nice, some are very rude. They are…

  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 · Dcited before2025-11-25 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide 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 interview and record review the facility failed to initially identify a pressure ulcer and put interventions in place to prevent the area from worsening for a resident at high risk for developing pressure ulcers. This applies to 1 of 3 residents (R5) reviewed for pressure ulcers in the sample of 18. The findings include: R5's EMR (Electronic Medical Record) shows that R5 was admitted to the facility on [DATE] with diagnoses including right femur fracture, second lumbar vertebrae fracture, right acetabular fracture, complicated by acute hypoxia, respiratory failure and hypokalemia following a motor vehicle accident. R5 was discharged back to the hospital on [DATE] due to hypokalemia and elevated white blood cell count. R5's Wound Assessment Details Report dated 11/11/25 shows that R5 has a left buttocks wound measuring 9.0 x 11.0 x 0.10cm (centimeters) with a scant amount of serosanguineous exudate. The wound is described as facility acquired MASD (moisture associated skin damage).The Wound Physician…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-11-25 · tag F0694 — isolated
  Provide for the safe, appropriate administration of IV fluids for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review the facility failed to ensure sterile catheter dressing changes were performed for a resident with a PICC (Peripherally Inserted Central Catheter) this applies to 1 of 3 residents (R2) reviewed for central lines in the sample of 18. The findings include: On 11/21/25 at 8:28 AM, R2 was in her room lying in bed. R2 said she had a PICC in her left upper arm placed on 9/16/25, because she had infection in her knee, and she was getting IV antibiotics. The staff were not changing the dressing weekly. She told the staff it needed to be changed weekly, and they said they did not know how to do change the dressing because they were not RN's (Registered Nurse's). R2 said her PICC line was removed because it got clogged.On 11/21/25 at 9:40 AM, V11 (RN) said PICC line dressings should be changed once a week. Only RN's can change the dressing on PICC lines and there should be an order when to change the dressing. On 11/21/25 at 3:05 PM, V2 (Director of Nursing-DON) said R2 had a PICC line for IV antibiotics. V2 said residents with PICC lines…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-11-25 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide 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 administer medications as ordered by the resident's physician. This applies to 1 of 3 residents (R1) reviewed for medication administration in the sample of 13.The findings include: On 11/21/25 at 9:45 AM R1 stated, It took 11 hours for me to finally get my Depakote. It was on September 20th. I talked to the night shift and then the day shift and then the swing shift and no one had time to give me my medication. Finally, it was given to me after Bingo (after 2PM). I should get it twice a day at 8AMand 8PM.On 11/21/25 at 3:15 PM V8 (Ombudsman) stated, I know she was really upset when she went the whole day without getting her medications.On 11/21/25 R1's Medication Administration Record for September was reviewed and shows no initials for the administration of Depakote (Anticonvulsant) 125 milligram (mg) at 8:00 AM or 8:00 PM on September 20, 2025. This same form also shows no initials for the administration of R1's Bupropion XL (Antidepressant) 300mg at 8:00 AM or her Abilify (Antipsychotic) 2mg at 8:00 PM. On 11/21/25 V2…

  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 · F2025-06-05 · 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 handle food in a manner to prevent cross-contamination and failed to maintain food preparation equipment in a manner to prevent cross-contamination. This failure has the potential to affect all 131 residents residing in the facility. The findings include: On 6/3/25 at 11:46 AM, V14, Cook, began the lunch service from the steam table in the kitchen. All residents in the facility were served from this steam table. The lunch menu was battered fish with a lemon wedge, french fries, and peas. The lemon wedges did not have any utensils for handling. V14 placed a lemon wedge on each plate with her gloved hand. V14 also used her gloved hand to move the peas into a pile on the plate and organize the french fries on the plate. V14 also used her gloved hand to steady the fish as she moved the fish from the steam table to the residents' plates. On occasion, V14 also picked up the fish with her gloved hand and placed it on the plate. During the lunch service, V14 pulled down her shirt with her gloved hands, touched door…

  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 before2025-06-05 · tag F0755 — failed to provide safe pharmacy services — pattern
  Provide 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 correctly transcribe a physician's order for 2 residents (R60,R129), failed to ensure the correct dose of a medication was given for 1 resident (R90), failed to ensure the correct medications were given for 1 resident (R25). These failures apply to 4 of 4 residents outside of the sample reviewed for medication errors. The findings include: 1) R25's electronic face sheet printed on 6/5/25 showed R25 has diagnoses including but not limited to cerebral infarction, insomnia, dementia with behaviors, anxiety disorder, and major depressive disorder. The facility's document titled, Safety Event Entry dated 4/9/25 showed, (R25) given incorrect medications including cetirizine 10mg, gabapentin 100mg, quetiapine 50mg, and memantine 5mg. Error noted by another RN (Registered Nurse) as I was exiting the room. Nurse Practitioner notified and advised to monitor resident .resident has no change from baseline . 2) R60's electronic face sheet printed on 6/5/25 showed…

  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.

Fines & penalties

$123,556 in federal fines across 5 penalties. 1 Medicare payment denial on record.

• $38,786 — penalty dated 2025-11-25
• $44,372 — penalty dated 2025-06-05
• $13,309 — penalty dated 2024-08-07
• $14,050 — penalty dated 2024-02-21
• $13,039 — penalty dated 2023-11-15
• Medicare payment denial — starting 2025-06-28 for 12 days

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

The source lists no ownership percentage for any party here — 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.

This home reported $1.5M paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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