Willows Health Center
4054 Albright Lane, Rockford, IL 61103 · Non profit - Corporation · 50 certified beds · (815) 316-1500 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (4/5)
- it has an abuse, neglect, or exploitation citation (F0602), cited Nov 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $12,909 in federal fines (most recent 2023-12-11)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 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 fell from 5 to 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 19.2% | 13.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.8% | 6.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.4% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 54.2% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.7% | 3.1% | 3.3% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 15.4% | 18.3% | 18.9% | better |
| Long-stay residents with pressure ulcers | 2.7% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 31.4% | 20.6% | 21.2% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.4% | 2.2% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 34.4% | 63.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 27.5% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 18.3% | 13.9% | 12.0% | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
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.
72.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 106 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 56.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 84 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 0.52 therapist hours per resident per day in 2026Q1 — more than 83% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 16% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 72.7%CMS range 60.0–79.5 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 8.3%CMS range 5.5–12.0 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 56.0% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 56.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 61.9% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 96.6% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.8% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.8%CMS range 3.4–10.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.68 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 50 beds and averages 30.3 residents a day — about 61% occupied, or roughly 20 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 5.21 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.92 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.31 hrs/resident/day on weekends vs 5.57 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 1.90 to 0.85 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
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.
26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.
- Actual harm · Gcited before2025-11-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow speech therapy recommendations for a resident (R46) at risk for aspiration. The facility also failed to ensure a resident (R1) at high risk for falls and exhibiting restless behaviors was supervised. This failure resulted in (R1) falling from her wheelchair and sustaining a right hip fracture. This applies to 2 of 16 residents (R1, R46) reviewed for safety and supervision in the sample of 16.The findings include:1.) R1's face sheet shows she has diagnoses including Alzheimer's Disease, dementia, anxiety disorder, weakness, and a fracture of the neck of the right femur. R1's active care plan initiated 1/8/25 shows she has a cognitive impairment, requires extensive assistance with her Activities of Daily Living/ADL's, requires a mechanical lift for transfers, and is at high risk for falls. Interventions listed on the care plan include prompt response to all requests for assistance, a bed and chair alarm and to encourage resident to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-01-26 · tag F0839 — widespreadEmploy staff that are licensed, certified, or registered in accordance with state laws.
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 nursing staff were working with an active nursing license which applies to all 91 residents in the facility. The findings include:The Facility Data Sheet dated 1/26/26 showed the facility had a current census of 91 residents.The facility's undated copy of V3's (Licensed Practical Nurse/LPN) from the state licensing agency summary showed V3's license was suspended from 12/15/25 through 12/24/25.V3's Timesheet Summaries printed on 1/26/26 showed V3 worked on 12/16/25, 12/19/25, and 12/23/25 during their license suspension.The Facility's Daily Census Sheets printed on 1/26/26 showed the on 12/16/25 was 67, 0n 12/19/25 the census was 64, and on 12/23/25 the census was 66.On 1/26/26 at 10:20 AM, V2 (Human Resources) stated V3 did not let us know their LPN license was temporarily suspended. Nurses should not work while their licenses are suspended.The state licensing agency's frequent asked questions showed suspended licensees are prohibited form practice during the suspension term and may be subject to certain terms and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-16 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to prevent a resident from acquiring a new pressure ulcer. This applies to one of three residents (R1) reviewed for pressure ulcers in the sample of six.The findings include:The facility face sheet for R1 shows she was admitted to the facility on [DATE] with diagnoses to include pathological fracture to left femur, congestive heart failure, atrial fibrillation and osteoporosis. The facility assessment dated [DATE] shows R1 to be cognitively intact and requires maximum assistance with transfers and rolling in bed. The admission nursing note dated 11/13/2025 shows R1 was admitted with a surgical wound to her left hip and no other areas of concern were observed or documented. On 12/16/2025 at 12:55 PM, V2 (Licensed Practical Nurse) and Nurse Manager said when R1 was admitted to the facility, she completed her admission skin check and R1 did not have any open areas or redness to her heels. V2 said on 11/20/2025 she was alerted by staff that R1 had a pressure…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-11-25 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review that facility failed to store food in a sanitary manner and failed to ensure the cooking areas were clean and sanitary. This applies to all 35 residents residing at the facility. The findings include:The CMS 671 Long-term Care Facility Application for Medicare and Medicaid Form dated 11/24/25 shows that there are 35 residents residing in the facility. On 11/23/25 at 9:56 AM, during tour of the kitchen, there was an opened box of French baguettes stored directly below the condenser/evaporator in the walk-in freezer. There was an unwrapped French baguette sticking out of the top of the box. The box had ice build-up on the outside of the box. The exhaust hood had a build-up of dust debris on the fire suppression lines that were directly above the cooking area. On 11/23/25 at 9:56 AM, V26 (Corporate Executive Chef) took the box of French baguettes out of the freezer and disposed of the top baguettes and said that that they should not be stored the way they were stored. On 11/24/2025 at 2:37 PM, V27 (Dietary Liaison) said that food in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-11-25 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide meaningful activities to dementia residents for 4 of 16 residents (R23, R11, R26, R35,) reviewed for activities in the sample of 16.The findings include:1. R23's electronic face sheet show R23 has with diagnosis of Alzheimer's dementia.On 11/23/25 at 9 AM, R23 was sitting in his wheelchair in front of the TV. At 9:30 AM, R23 was asleep. At 10:20 AM, during a family interview R23's son (V5) said he had been making a point to visit R23 on the weekends because there were no ongoing activities on either Saturday or Sunday. V5 said R23 was an Engineer in the past. V5 said he wanted R23 to engaged in activities.R23's Activity Care plan dated 6/12/25 documents The resident has impaired cognitive function/dementia or impaired thought processes r/t Dementia but has no activity intervention included in R23's care plan.2. R11's electronic face sheet show, R11's diagnoses include dementia, anxiety and mood disorders.On 11/23/25, at 9AM R11…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-25 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to have a system in place to ensure as needed (PRN) psychotropic medications had a stop date for 1 of 5 residents (R14) reviewed for psychotropic meds in the sample of 16.The findings include:R14's Physician Order sheet with an order date of 11/5/25 show an order of: Ativan 0.25 ml sublingual every 2 hours as needed for anxiety. The order had no stop date.On 11/24/25 at 3PM V12 (Nurse Manager) said he was in charge of psychotropic meds making sure psychotropic meds have diagnosis and stop dates. V12 said he was not aware of R14's antianxiety order with no stop date. V12 said this order was carried out by a Hospice staff. They should have clarified the order and got a stop date. V12 said he does not know why the order was placed in the electronic charting with no stop date. On 11/25/25 at 9AM V12 Nurse Manager presented a document for R14's antianxiety order but was not reflected in R14's medical record. V12 said all R14's ordered medications including psych meds with stop dates should be reflected in R14's medical record. V12…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-25 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide toileting assistance to a resident dependent on staff for cares in a timely manner for 1 of 16 residents (R46) reviewed for activities of daily living (ADLs) in the sample of 16.The findings include:R46's face sheet shows he was admitted to the facility on [DATE] and has diagnoses including Parkinson's disease and dementia. R46's admitting care plan shows he has an ADL self-care deficit due to weakness and requires assistance from staff. On 11/23/25 at 10:15 AM, R46's door was closed. Upon entering his room this surveyor observed R46 to be confused and very restless with his legs half on and half off the bed. R46 kept saying he had to stand up and use the bathroom. The surveyor put R46's call light on immediately to get staff assistance. R46 continued to appear very restless and hanging his legs over the side of the bed, the surveyor stayed by R46 continuously and encouraged him to remain in bed and wait for assistance. At 10:27 AM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-25 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide 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 interview and record review the facility failed to inform the dietitian of a resident's continued weight loss. The facility failed to obtain weights on a newly admitted resident as per facility policy. These failures apply to 1 of 4 residents (R47) reviewed for weight loss in the sample of 16.The findings include:R47's hospital progress note dated 10/24/25 showed R47 was hospitalized on [DATE] after being diagnosed with a subdural hematoma (brain bleed) where R47 subsequently underwent a craniotomy (brain surgery) on 10/22/25 to repair/drain the bleed. R47's facility admission record showed R47 was admitted to the facility on [DATE]. R47's admission care plan (dated 10/28/25) showed R47 was at risk for weight loss with a goal of Resident will maintain current weight. On 11/23/25 at 9:17 AM, R47 was seated in a recliner in his room. R47 was alert and cognitively intact. R47 stated he recently had brain surgery because they found bleeding in my brain. R47 stated he was transferred to the facility for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-25 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents medications were available for administration for 2 of 16 residents (R46,R56) reviewed for pharmacy services in the sample of 16.The findings include: 1.R56's admission Record showed R56 was admitted to the facility on [DATE]. Physician orders dated 11/21/25 showed R56 was to receive D-Mannose Oral Capsules (supplement to prevent urinary tract infections) 500 mg; give 4 capsules by mouth three times a day and Simvastatin 40 mg; give one tablet once a day. On 11/24/25 at 8:20 AM, V8 (Registered Nurse/RN) prepared and administered R56's morning medications to R56. V8 stated, I can't give (R56's) D-Mannose medication. We don't have it. It looks like we haven't gotten it from our pharmacy. We don't have that medication in our (stock medication cart). We also don't have her Simvastatin, but I can pull that medication from our (stock medication cart). V8 walked over to the facility's (stock medication cart). V8 removed a dose of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-25 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the required personnel protective equipment was worn in a covid isolation room and failed to implement enhanced barrier precautions for a resident with a peripherally inserted central catheter line (PICC) for 2 of 16 residents (R46, R48) reviewed for infection control in the sample of 16.The findings include: 1.) R46's face sheet shows he was admitted on [DATE] and has Covid-19 infection. R46's Physician order summary shows he is on contact and droplet precautions for Covid-19. On 11/23/25 at 10:16 AM, there were 2 signs outside R46's doorway indicating that he is on contact and droplet precautions and gowns, gloves, face shields or goggles, and masks should be worn inside the room. There was a plastic bin outside the room containing all the required PPE to enter his room. At 10:27 AM, V20 (Certified Nursing Assistant/CNA) entered R46's room with no PPE on at all and turned off R46's call light. On 11/23/25 at 11:44 AM, V21…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-25 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 residents who were eligible for a pneumococcal vaccine according to the Centers for Disease Control and Prevention (CDC) were offered the vaccine for 2 of 5 residents (R23 and R36) reviewed for immunizations in the sample of 16. The findings include:1.R23's Face Sheet shows that he admitted to the facility on [DATE] and is [AGE] years old. R23's Immunizations Report shows that he has not received a pneumococcal vaccine. R23's Progress Note dated 3/11/22 shows, [R23] shares that he received the Pneumococcal 23 vaccination after age [AGE].No other documentation of a pneumococcal vaccine was provided for R23. 2. R36's Face Sheet shows that she was admitted to the facility on [DATE] and is [AGE] years old. R36's Immunizations Report shows that she received the Pneumococcal 23 vaccine on 12/8/21 and no other pneumococcal vaccines were documented as administered. No other documentation of a pneumococcal vaccine was provided for R36. On 11/25/25 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 15 citations
- Potential for harm · D2025-11-15 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident was free from misappropriation for 1 of 3 residents (R2) reviewed for misappropriation in the sample of 3.The findings include:R1's face sheet showed R1 was admitted to the facility on [DATE] with diagnoses to include atherosclerotic heart disease, insomnia, spinal stenosis, dementia with psychotic disturbance, panic disorder, restlessness and agitation, and mood disorder.R2's face sheet showed R2 was admitted to the facility on [DATE] with diagnoses to include anemia, chronic congestive heart failure, hypertension, gout, restlessness and agitation, dementia with behavioral disturbance, and anxiety disorders. R1's physician order sheet showed no order for liquid Ativan obtained until 9/25/25. R2's September 2025 eMAR (electronic Medication Administration Record) showed an order for Lorazepam Oral Concentrate 2ML/ML, give 0.5 ml by mouth every 1 hour as needed for agitation and anxiety.R1's September 2025 eMAR showed no order for liquid…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-15 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure a resident was free of a medication error for 1 of 3 residents (R1) reviewed for medication administration in the sample of 3.The findings include:R1's face sheet showed R1 was admitted to the facility on [DATE] with diagnoses to include atherosclerotic heart disease, insomnia, spinal stenosis, dementia with psychotic disturbance, panic disorder, restlessness and agitation, and mood disorder.R1's undated care plan showed, The resident uses anti-anxiety medications related to anxiety disorder. Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness every shift.R2's face sheet showed R2 was admitted to the facility on [DATE] with diagnoses to include anemia, chronic congestive heart failure, hypertension, gout, restlessness and agitation, dementia with behavioral disturbance, and anxiety disorders. R1's physician order sheet showed no order for liquid Ativan obtained until 9/25/25. R2's September 2025…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-28 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to complete a thorough investigation into an allegation of misappropriation of narcotic medications. This applies to four of four residents (R4-R7) in certified beds of the facility reviewed for abuse investigation in the sample of 13. The findings include: The facility census provided by the facility dated 1/28/2025 for December 24 to December 25, 2024 shows there were four residents residing in certified beds in the E-wing that also had orders for controlled medications. The facility provided a schedule for 12/24/24 which shows V21 (Agency Licensed Practical Nurse/LPN) was assigned the E-wing unit of the health care center from 2:00 PM to 10:30 PM. On 1/21/25 at 12:30 PM, V3 (Director of Nursing/DON) said, . It was [V21 Agency LPN] that was accused. She worked for us for that one day and only worked on the sheltered care side of the facility. She would not have had access to any other medication carts, medication rooms, or comfort packs on any other unit. On 1/22/25 at 3:30 PM, V3 (DON) said no concerns were reported to her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-28 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure a narcotic count was completed upon nursing shift change. This applies to one of one resident (R6) in certified beds of the facility reviewed for narcotic counts in the sample of 13. The findings include: The facility face sheet for R6 shows he was admitted to the facility with diagnoses to include encounter for palliative care, hypertensive heart disease with heart failure, atrial fibrillation, dementia, and congestive heart failure. The medication administration record for R6 shows medication orders for lorazepam (anti-anxiety medication) 2 mg/ml (milligrams/milliliters) give 0.5 ml every four hours as needed and morphine (opioid pain medication) 20 mg/ml give 0.25 ml every four hours as needed. (Lorazepam and morphine are controlled substances.) On 1/21/25 at 2:20 PM, V22 (Registered Nurse/RN) said, I had worked night shift on Christmas Eve. I was late and did not get there until 11:00 PM. I did not count the narcotics, I assumed it was done by someone else. The next morning when I went to count with the day shift…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure a resident was positioned safely in bed to prevent a fall for 1 of 3 residents (R2) reviewed for safety and supervision in the sample of 5. The findings include: The Nurse's Note dated 9/20/24 at 8:30 PM showed, Resident (R2) was found at 7:30 PM by CNA (Certified Nursing Assistant) staff at the time this writer arrived resident vitals were assessed and stable. Client told staff she wanted to get her cranberry juice and slid out of her bed. No signs of distress or discomfort shown by client. Client expressed her bottom was hurting but she did not have any other pain. This writer reached out to clients POA with direct phone call and advised client would have to be sent out for further evaluation per standard protocol due to client being on blood thinner medication. On 9/21/24 at 1:00 AM staff was contacted by the hospital nurse and was notified that the resident was being admitted for a subarachnoid bleed. On 9/21/24 at 7:07 PM, Nurse to nurse report given by hospital nurse to this writer/nurse - the hospital…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-08-22 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
3. On 8/21/24 at 1:14 PM, R10 was sitting in the recliner in his room. V8 (Certified Nursing Assistant/CNA) and V9 (CNA) had mask and gloves on when entering R10's room. V8 and V9 used a mechanical lift device to transfer R10 from his recliner to his bed. Once R10 was transferred to bed, V8 and V9 rolled him back and forth to remove the sling and adjust the linen under him. R10 had a wrinkled dressing to his left buttock, a dressing to his right knee, and dressings to his bilateral lower legs. V8 and V9 stated there was no reason to wear gowns for this activity. V8 stated there wasn't a sign on the door saying they needed to wear anything. V9 stated she just goes by whatever the sign that is posted states to do. V9 stated she didn't see any signs or isolation cart outside R10's room. On 8/21/24 at 1:26 PM, V7 (Licensed Practical Nurse/Nurse Manager) stated they did not have anyone on enhanced barrier precautions. V7 stated R10 has wounds but has not needed to be on any precautions. V7 stated she did not know about enhanced barrier precautions. V7 stated they have never worn gowns…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-08-22 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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 observation, interview, and record review the facility failed to treat 8 residents with dignity. This applies to 4 of 4 residents (R6, R11, R12, R17) reviewed for dignity in the sample of 13 and 4 residents (R2, R9, R22, R23) outside of the sample. The findings include: On 8/21/24 at 11:35AM, R2, R6, R9, R11, R12, R17, R22, and R23 were being served their noon meal. All residents received their water, fruit cups, pasta salad, and cucumber tomato salads in disposable plastic cups. On 8/21/24 at 12:42PM, V12 (Dietary Manager) stated, The kitchen staff measured the food and placed them in plastic cups. They should have then placed the food into the small bowls we have but they forgot to. It's a dignity concern that they left everything in plastic cups because they should feel like they are eating with normal dishes. We only use disposable dishes if a resident is on isolation or if we have a malfunction with our dish machine. This was not the case today and my staff should know better. Any reasonable person would want to eat with regular dishes, not disposable. The facility's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-22 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete weekly wound assessments for a resident (R17) with a stage 2 pressure ulcer, failed to ensure complete weekly wound assessments were done for a resident (R10) admitted with a stage 3 pressure ulcer. These failures apply to 2 of 2 residents reviewed for pressure ulcers in the sample of 13. The findings include: 1. R17's electronic face sheet printed on 8/22/24 showed R17 has diagnoses including but not limited to pressure ulcer of sacral region, dysphagia, dementia with behaviors, and anxiety disorder. R17's facility assessment dated [DATE] showed R17 has a Stage 2 pressure injury. R17's care plan dated 3/19/20 showed, At risk for Impaired Skin Integrity. Wound to buttocks .monitor wound progress and document and measure weekly. R17's weekly wound assessments from 6/2/24-8/2/24 showed R17 did not receive a weekly wound assessment from 6/25/24-8/2/24 (4 weeks). On 8/22/24 at 12:33PM, V15 (Director of Nursing/DON) stated, We do not have all of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-22 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure a catheter tubing remained free of kinks and the catheter tubing secure device was in place for 1 of 1 resident (R25) reviewed for catheters in the sample of 13. The findings include: On 8/20/24 at 1:35 PM, R25 was in his room in his recliner. R25 had an indwelling urinary catheter drainage bag attached to the lower part of his wheeled walker. R25 had thick white sediment and cloudy yellow urine in his catheter tubing. R25 did not have a catheter tubing secure device in place. R25 stated he has not had one (catheter secure device) on for two weeks. R25 stated they must have run out of them. R25 stated he wouldn't mind having one (catheter secure device) on now. R25 said it would help prevent his catheter from coming out. R25 stated his catheter is leaking right now. On 8/20/24 at 1:47 PM, V10 (Licensed Practical Nurse) stated, R25 had some pressure so to be on the safe side they collected a urine sample. V10 stated R25's tubing was kinked and that is why they took a urinalysis. V10 stated sometimes when…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-21 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide feeding assistance to residents in a dignified manner. This applies to 2 of 3 residents (R9, R14) in the sample of 12 and 1 resident (R6) outside of the sample reviewed for dignity. The findings include: On 9/20/23 at 8:05AM R6, R9, and R14 were being assisted with their breakfast meal. V12 (Registered Nurse) assisted R9. V13 (Certified Nursing Assistant/CNA) assisted R14. V14 (CNA) assisted R6. V12, V13, and V14 were all standing over residents while feeding them. No chairs were present for the staff to sit with each resident they were assisting. V13 stated, We sit sometimes with the residents but today we just decided to stand. It depends on how many residents we have to feed and how busy we are. We should sit with them to make them feel like we aren't rushing them. On 9/21/23 at 9:30AM V2 (Director of Nursing) stated, CNAs should be sitting when feeding residents for dignity purposes. Residents should feel like staff are not rushing them and when they stand, I can see how residents would feel…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-21 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide incontinence care for dependent residents prior to their briefs and clothing becoming soiled for 2 of 5 residents (R1, R3) reviewed for incontinence in the sample of 12. The findings include: 1) R1's electronic face sheet printed on 9/21/23 showed R1 has diagnoses including but not limited to Alzheimer's disease, hypertensive chronic kidney disease, dementia without behaviors, and vascular dementia with behaviors. R1's facility assessment dated [DATE] showed R1 has severe cognitive impairment and is always incontinent of bowel and bladder. R1's care plan dated 2/19/19 showed, Urinary incontinence related to decreased independence with mobility activities and cognitive status. Provide for adult clothing protectors and monitor for incontinence every 2 hours. Dependent on staff with incontinence care. On 9/20/23 at 12:53PM, V11 and V13 (Certified Nursing Assistants/CNA) provided incontinence care to R1. V11 rolled R1 over and R1 had a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-21 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to timely obtain an antibiotic order for a resident with symptoms of a urinary tract infection. This applies to 1 of 3 residents (R4) reviewed for quality of care. The findings include: R4's Profile Face Sheet showed a current admission date of 1/27/23 with diagnoses to include heart failure, Alzheimer's disease, and chronic pain. On 9/19/23 at 2:24 PM, V18 (R4's Daughter/Power of Attorney) stated R4 became septic (blood infection) from a urinary tract infection, and she is now on hospice care. V18 stated regarding the urinary tract infection, R4 was having mental status changes. R4's Nurse's Note from 8/8/23 at 4:43 AM showed, [On 8/7/23 at 6:00 PM] R4 was in bed fully dressed over her blankets. CNA (Certified Nursing Assistant) attempted to assist resident with HS (Bedtime) care; became verbally aggressive. CNA stepped away allowed resident to rest. Approached several times through the night. By 10:00 PM resident continued to refuse. The nurse approached, resident was hallucinating, reaching, and scratching at the wall.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to complete a fall assessment and implement fall prevention measures for a resident at risk for falls for 1 of 1 resident (R3) reviewed for falls in the sample of 12. The findings include: R3's electronic face sheet printed on 9/21/23 showed R3 was admitted to the facility on [DATE] and has diagnoses including but not limited to left femur fracture, osteoporosis, chronic pain, pain in left leg, and history of falls. R3's facility assessment dated [DATE] showed R3 has severe cognitive impairment, has had a fall in the past 2-6 months, and has had a fall with a fracture. The facility's accident/incident reports showed R3 experienced a fall on 3/7/23, 4/18/23, 5/16/23, and 5/20/23. R3's sustained a hip fracture with her fall on 5/20/23. R3's care plan dated 6/16/23 (4 months after R3 was admitted ) showed, Potential for falls related to history of falling, requires assistance for transfers & ambulation, generalized weakness, recent fall with a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-21 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident's pain medication was administered as ordered for 1 of 1 resident (R126) reviewed for pain in the sample of 12. The findings include: R126's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include encounter for surgical aftercare following surgery on the digestive system, osteoarthritis, obesity, moderate persistent asthma, benign neoplasm of ascending colon, and generalized anxiety disorder. R126's care plan initiated 9/14/23 showed, Pain . Alteration in comfort related to cervical spondylosis without myelopathy, OA (osteoarthritis), knee pain. Baclofen for muscle spasms. Pain control as evidenced by verbalizing satisfaction with level of comfort, ability to participate in ADL's (Activity of Daily Living) without discomfort. Early detection of pain for timely intervention to prevent escalation . Assess pain level as evidenced by reported pain, restlessness, pupil dilation, perspiration,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-21 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure medications were received from pharmacy in a timely manner for 1 of 1 resident (R126) reviewed for medications. The findings include: R126's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include encounter for surgical aftercare following surgery on the digestive system, osteoarthritis, obesity, moderate persistent asthma, benign neoplasm of ascending colon, and generalized anxiety disorder. R126's care plan initiated 9/14/23 showed, Pain . Alteration in comfort related to cervical spondylosis without myelopathy, OA (osteoarthritis), knee pain. Baclofen for muscle spasms. Pain control as evidenced by verbalizing satisfaction with level of comfort, ability to participate in ADL's (Activities of Daily Living) without discomfort. Early detection of pain for timely intervention to prevent escalation . Assess pain level as evidenced by reported pain, restlessness, pupil dilation, perspiration, changes 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$12,909 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $12,909 — penalty dated 2023-12-11
- Medicare payment denial — starting 2025-12-18 for 15 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
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| SALINAS, FRANCES | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | since 07/01/2022 |
| DITTMER, HELEN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 07/01/2021 |
| NELSON, BRETT | Individual | CORPORATE OFFICER | since 07/01/2021 |
CMS files one row per role, so the 5 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 146101. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-25, 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 →
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