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Rushville Nursing & Rehab Ctr

135 South Morgan Street, Rushville, IL 62681 · For profit - Limited Liability company · 96 certified beds · (217) 322-3201 Medicare & Medicaid certified

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Flagged for abuseBehavioral-health or dementia-care citation — no harm found (F0758)2 immediate-jeopardy citations
Insights

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

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2026
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)

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

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

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
233 S Congress St · (217) 322-3345 · Call to confirm hours
Pharmacy
124 N Congress St · (217) 322-3335 · Call to confirm hours
Grocery
123 N Liberty St · (217) 322-4860 · Call to confirm hours
Park
417 E Jefferson St · (217) 322-3028 · Typically dawn to dusk
Place of worship
217 S Liberty St · (217) 322-3717

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 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.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased6.5%13.4%15.4%better
Long-stay residents who lose too much weight5.7%6.3%5.4%typical
Long-stay residents with a catheter left in their bladder5.3%0.9%0.9%worse
Long-stay residents with a urinary tract infection1.5%1.5%2.0%better
Long-stay residents with depressive symptoms96.5%54.2%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury5.7%3.1%3.3%worse
Long-stay residents whose ability to walk worsened5.4%14.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication13.0%18.3%18.9%better
Long-stay residents given the seasonal flu vaccine96.9%91.8%95.3%typical
Long-stay residents with pressure ulcers7.5%4.8%4.7%worse
Long-stay residents with worsening bladder/bowel control23.7%20.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table13.6%21.7%17.1%better
Short-stay residents who newly got an antipsychotic medication4.5%2.2%1.4%worse
Short-stay residents given the seasonal flu vaccine93.3%63.1%79.4%better
Short-stay residents rehospitalized after admission19.9%26.1%22.6%better
Short-stay residents with an outpatient ER visit14.8%13.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.832.021.67typical
Long-stay outpatient ER visits per 1,000 resident days3.482.221.80worse

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

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

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

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

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

40.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 36 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

40.7%U.S. median 51.5%
Got home and stayed home
11.6%U.S. median 10.7%
Went back to hospital
60.9%U.S. median 56.6%
Met the expected recovery
0.21U.S. median 0.31
Therapy hours / resident / day
0.10hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 60.9% 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 23 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 0.21 therapist hours per resident per day in 2026Q1 — more than 26% 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.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF40.7%CMS range 27.9–54.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.6%CMS range 7.8–18.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge60.9%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge52.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge60.9%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay3.1%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.4%CMS range 3.4–13.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.351.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.89
RN hours/ resident / day
0.39
LPN hours/ resident / day
1.83
Aide hours/ resident / day
3.11
Total nurse hours/ resident / day
0.67
RN hoursweekends
46.8%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 96 beds and averages 74.2 residents a day — about 77% occupied, or roughly 22 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 3.11 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.89 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.83 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 2.57 hrs/resident/day on weekends vs 3.33 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 0.98 to 0.67 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%.

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

Inspection trend

10
deficiencies at the latest standard inspection (2025-04-09)
5
at the previous standard inspection (2024-06-13)

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.

ABCDEFGHIJKL

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

27 citations, most serious first. The 14 most serious are shown; the remaining 13 are one tap away and print in full.

  • Immediate jeopardy · J2026-06-01 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure staff respected R1's right to refuse care, failed to prevent staff from using physical force during care, and failed to protect R1 from abuse when staff held R1's arms and hands down and provided care against R1's expressed refusal while R1 repeatedly yelled No, Get off me, and Let go of me. These failures resulted in R1 being manually restrained during care, caused R1 fear, distress, and psychosocial harm, and created Immediate Jeopardy to resident health and safety.These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 10/28/25 when staff forced care on R1 despite R1's refusal and signs of distress. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 5/28/26 at 9:25 am. While the immediacy was removed on 5/30/26, the Facility's noncompliance remained at a Severity Level Two due to the need for additional monitoring to evaluate the implementation and effectiveness of the facility's plan of correction.Findings include: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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · Jcited before2026-06-01 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure timely assessment, monitoring, physician notification, diagnostic evaluation, and intervention for significant changes in condition related to urinary catheter complications and signs and symptoms of urinary tract infection (UTI) for one (R1) of three residents reviewed for urinary catheters in the sample of three. The facility failed to recognize, investigate, escalate, and respond to repeated abnormal urinary findings and changes in condition despite R1's known history of recurrent UTIs, urosepsis, and rapid clinical decline requiring prior hospitalizations. The facility's repeated failure to identify and respond to ongoing signs and symptoms consistent with urinary tract infection and catheter complications resulted in delayed medical treatment and caused R1 to experience acute clinical deterioration, respiratory distress, sepsis secondary to urinary tract infection, supraventricular tachycardia requiring cardioversion, mechanical ventilation…

    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 before2024-12-04 · 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 utilize a gait belt during ambulation, for one resident (R2) of three residents, in a total sample of three residents reviewed for supervision. This failure resulted in R2 being hospitalized , with a femur fracture which required surgical intervention. Findings Include: Facility Policy, entitled Gait Belts, dated 4/13, document, Gait belts are used to help prevent injury of staff or residents during transfers and ambulation; 1. Gait belts should be used by all staff when ambulating or transferring a resident with an unsteady gait. R2's Electronic Medical Record/EMR document R2's diagnosis to include: Displaced supracondylar fracture with intracondylar extension of lower end of left femur, Muscle wasting and atrophy, Muscle Weakness, Chronic obstructive pulmonary disease, Heart Disease, Hypertension, Peripheral vascular disease, Displaced fracture of proximal phalanx of left lesser toe, Displaced fracture of proximal phalanx of right little…

    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 · G2023-05-25 · 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 observation, record review and interview, the facility failed to implement pressure relieving interventions and perform daily Diabetic foot skin assessments for one of two residents (R47) reviewed for impaired skin integrity, in a sample of 27. These failures resulted in R47 developing unstageable pressure ulcers to the right and left heel after being admitted to the facility, which lead to osteomyelitis of the left heel and a delay in his discharge back to home. Findings include: The facility policy, titled Pressure Ulcer and Wound Prevention/Management Program (updated 12/05/2006) documents, Purpose: To identify residents who are at risk for pressure ulcers and skin breakdown. To prevent pressure ulcers and skin breakdown. To provide a guideline for the appropriate nursing management of skin breakdown when it occurs. Responsibility: Director of Nursing, Licensed Nurses, Certified Nursing Assistants, Restorative Nursing, Care Plan Coordinator, Dietitian, Physician and Medical Director. Policy: It is…

    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 · D2026-06-01 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the Facility failed to notify medication changes to a Resident Representative for one of seven Residents (R1) reviewed for new medications in a sample of seven.Findings include:The Notification of Change Guideline Policy, dated 10/1/24, documents: it is the practice of the Facility that changes in Resident condition or treatment are immediately shared with the Resident or Resident Representative, according to their authority, and are reported to and consulted with the attending physician; resident/resident representative will be educated about treatment options and supported to make an informed decision; objective of the notification guidelines is to ensure Facility staff make appropriate and immediate notification to the Resident and/or Representative when there is a change in condition (significant treatment alteration including commencing a new form of treatment; document the notification and record any new orders in the Residents medical record; educate the Resident/Resident Representative about the plan to treat, risks and benefits of 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 before2025-08-14 · 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 record review and interview the Facility failed to initiate appropriate fall interventions for one of four Residents (R6) reviewed for falls in a sample of six.Findings include:The Facility Fall Clinical Protocol Policy, revised 8/2008, documents: as part of the initial assessment, the Physician will help identify individuals with a history of falls and risk factors for subsequent falling; staff will continue to collect and evaluate information until either the cause of falling is identified, or it is determined that the cause cannot be found, or that finding a cause would not change the outcome or management of falling and fall risk; based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling; and staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling.The Facility Resident Rights Policy, dated 2007, documents Personal Safety, the Resident has the right to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-04-09 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to perform hand hygiene after glove removal for two (R41 and R119) of 18 reviewed for infection control and failed to adhere to masking during an influenza outbreak. The failure of non-masking has the potential to affect all 71 residents currently residing in the facility. Findings Include: The Facility's undated Preventing and Controlling ARI (Acute Respiratory Illness) in Skilled Nursing Facilities and Other Facilities Providing Nursing Care documents Ensure everyone, including residents, visitors, and HCP (Health Care Providers) are aware of recommended Infection Prevention and Control (IPC) practices in the facility, including when specific IPC actions are being implemented in response to new infections in the facility or increases in respiratory virus levels in the community. Source control is recommended for individuals in health care settings who have suspected or confirmed respiratory infection or respiratory trends or observed trends). The facility Urinary Catheter Care policy and procedure, dated…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-09 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    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 food stays warm for six residents (R11, R12, R26, R47, R50, and R119) of six residents reviewed in a total sample of 33. Findings Include: The Facility's undated Hot Food Service Temperatures policy documents foods will be served to the residents at a temperature that is palatable to prevent injury such as burned mouth or lips. Food will be offered to be reheated if it is not within resident's preferred food temperatures or another tray will be offered. On 4/8/25 at 8:30 AM R11, R12, R26, R47, R50, and R119's breakfast trays were sitting out on the dining room tables with either a lid or other plates on top of the dishes. R11, R12, R26, R47, R50, and R119 were not in the dining room at this time. On 4/8/25 at 8:35 AM V4 (Certified Nurse Aid/Transportation) stated that these residents had not come out to the dining room yet and she wasn't sure how long the trays had been sitting at the tables without residents present. V4 stated that staff routinely deliver trays to the resident's regular spot whether 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-09 · tag F0881 — failed to use antibiotics responsibly — pattern
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to identify, monitor, and review prophylactic antibiotic use for four of four residents (R17, R21, R38, R49) for antibiotic stewardship in the sample of 33. Findings include: The Infection Prevention and Control Program dated 2019 documented an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. Antibiotic Stewardship and review including reviewing data to monitor the appropriate use of antibiotics in the resident population. The Infection Preventionist will oversee the facility Antibiotic Stewardship Program. review of the use of antibiotics is a vital aspect of the infection prevention and control program. Involve the consultant pharmacist with the oversight by identifying antibiotics prescribed for resistant organisms. Track antibiotic use monthly and completes an antibiogram yearly or as directed by the Medical Director and the Quality Assurance Committee. The Antibiotic Stewardship Policy dated…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-09 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to ensure that a resident was treated with respect for one resident (R46) of 18 residents reviewed for respect and dignity in a total sample of 33. Finding Include: The Facility's undated Personal Cell Phone Use documents purpose: to assure that the resident privacy issues are maintained and to eliminate any distraction from responsibilities and duties. Personal cell phones must be turned off when reporting for work and stored in the employee's purse, car, or locker. They are not allowed to be carried on the employee's person while actively working. Employees may check/use their cell phones during break times only Please note employees may not bring the cell phone into any resident areas at any time regardless to break status. On 4/8/25 at 8:30 AM V4 (Transportation/Certified Nurse Aid) was in the dining room assisting R46 while eating. V4 had a utensil in one hand feeding R46 while looking at her phone and texting on her phone with her other hand. V4 stated she did not normally use her phone during cares. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-09 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure chemical restraints were not utilized for one resident (R12) of five residents reviewed for psychotropic medication in a total sample of 33. This failure resulted in over sedation and physical functioning for R12. Findings Include: The Facility's Abuse Prevention Policy and Procedure, dated 2/2020, documents Chemical Restraint is any drug that is used for discipline or convenience and is not required to treat medical symptoms or behavior manifestations of mental illness. The Facility's undated Psychopharmacological Drug Use Procedure documents the procedure is to assure the appropriate monitoring is provided to residents receiving psychopharmacological drugs, that the lowest possible dose necessary for the benefit of the resident to improve or control mood, mental status and/or behavior is utilized, and to reduce or eliminate the usage of these medications. The Facility's undated Psychopharmacological Drug Use Procedure documents…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-09 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview the facility failed to obtain a Preadmission Screening and Resident Review (PASRR) after a significant change in condition for one resident (R12) of one reviewed for PASRRs in a total sample of 33. Findings Include: The Facility Admission policy dated November 2016 documents PASSR screens must be valid and reviewed on admission, annually and upon any significant change. All residents with a newly evident or possible serious mental disorder, intellectual disability, or a related condition should be referred for a level II resident review upon a significant change in status admission. R12's admission Physician Order Sheet dated March 2024 documents R12 was admitted with diagnoses that include but were not limited to conversion disorder with seizures, dementia and anxiety. R12's admission Physician Order Sheet did not include any serious mental illness diagnosis. R12's PASSR Level I dated 3/26/2024 did not document any serious mental illness diagnosis. R12's Nurse's Note dated 11/15/2024 document that R12 was sent to the hospital due to increased…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-09 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to ensure indwelling urinary catheters were placed securely off the floor in a sanitary manner for two (R41 and R119) of six residents reviewed for indwelling urinary catheters in the sample of 33. Findings include: The facility Urinary Catheter Care policy and procedure, dated September 2005, documents The purpose of this procedure is to prevent infection of the resident's urinary tract. Be sure the catheter tubing and drainage bag are kept off the floor. 1. The current Physician Orders for R41 documents a 7/29/24 physician order for R41 to use a 16 FR (french)/10cc (cubic centimeter) balloon indwelling urinary catheter for the diagnosis of Urinary Retention. The current Care Plan for R41 documents R41 requires an indwelling urinary catheter for a diagnosis of Urinary Retention and requires Enhanced Barrier Precautions due to placement of indwelling urinary catheter. The documented goals as follows: R41 will have catheter care managed appropriately with no signs of infection and to reduce the spread 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to ensure oxygen tubing is changed weekly and ear pads are used for residents wearing oxygen for two (R25 and R119) of two residents reviewed for respiratory care in the sample of 33. Findings include: The facility Oxygen Administration policy and procedure, dated March 2004, documents The purpose of this procedure is to provide guidelines for safe oxygen administration. Securely anchor the tubing so that it does not rub or irritate the resident's nose, behind the resident's ears, etc. Place ear protectors as needed for residents utilizing oxygen more than 8 hours a day. Observe the resident upon set up and periodically thereafter to be sure oxygen is being tolerated. If the resident refused the procedure, the reasons(s) why and the interventions taken are to be documented in resident medical record. Notify the supervisor if the resident refuses the procedure. 1. The Progress Note for R119, dated 4/2/25, documents R119 readmitted to the facility from the local hospital on 4/1/25 with diagnoses: Adult Failure to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · Dcited before2025-04-09 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to attempt gradual dose reduction for one resident (R12) and failed to have clinical indication for the use of an antipsychotic medication for one resident (R119) of five residents reviewed for psychotropic medications in the sample of 33. Findings include: The facility's Psychotropic Medication Policy and Procedure, dated February 2014, documents Policy: To establish the process for monitoring the use of and the reduction of doses of psychotropic medications without compromising the president's health and safety, ability to function appropriately, or the safety of others. 2. Residents shall not be given antipsychotic drugs unless antipsychotic drug therapy is necessary to treat a specific or suspected condition as diagnosed and documented in the clinical record or to rule out the possibility of one of the conditions listed in guidelines of recognized external review agencies. 3. Residents who receive antipsychotic drugs shall receive gradual…

    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 · D2025-04-09 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Hospice's coordinated communication and required documents were available and accessible to the facility staff. This deficiency affects one of one resident (R11) reviewed for Hospice care management in a sample of 33 residents. Findings include: The Hospice Services Policy not dated documented Hospice service will conduct assessments and develop a hospice plan of care which will be integrated with the resident's overall plan of care and maintained in the medical record or other location with the interdisciplinary care plan. All hospice service staff will write a progress note for each resident visit indicating treatment provided and pertinent information related to the resident's condition which is available in the medical record for all interdisciplinary staff to access. Hospice service staff will attend care plan conferences and participate in the resident's care planning process. The Long Term Care Hospice Service Agreement dated…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-13 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, observation and record review, the facility failed to ensure a call light was accessible within a resident's reach for 1 of 24 residents (R9) reviewed for accommodation of needs in the sample of 35. Findings include: The facility's Answering the Call Light policy (revised August 2008) documents the following: Call lights must be accessible to residents from their bed or other sleeping accommodation. On 06/10/24 at 10:25 AM, R9 was lying in bed watching television. R9's call light was clipped to a bedside commode that was approximately three feet out of her reach. R9 stated, They never give me my call light when I am in bed. It doesn't reach very well to my bed, so I always have to get out of bed to get it. I shouldn't have to get up to find my call light every time I need to use it. At 10:28 AM, V7 (Certified Nursing Assistant), entered R9's room and confirmed her call light is not within her reach. V7 stated, Well, let me wipe it down before I hand it to you since it's been clipped to your commode. On 06/13/24 at 01:35 PM, V3 (Registered Nurse) stated a call…

    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 before2024-06-13 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to ensure a PASARR (Preadmission Screening and Resident Review) was completed after a facility resident was later identified with a mental disorder for one of three residents (R31) reviewed for PASARR in the sample of 35. Findings include: R31's OBRA-I (Omnibus Budget Reconciliation Act) Initial Screen form (dated 06/01/21) documents screening indicated nursing facility services are appropriate, and R31's face sheet documents R31's primary diagnosis at time of admission [DATE]) to the facility was Guillain-Barre syndrome. R31's Current Diagnosis documents R31 was later diagnosed with Schizoaffective Disorder on 02/24/22. R31's medical record does not include a Preadmission Screening and Resident Review after R31 was diagnosed with Schizoaffective Disorder on 02/24/22. On 06/13/24 at 09:53 AM, V5 (Social Service Director) stated R31 never had a PASARR completed when she was diagnosed with Schizoaffective Disorder on 02/24/22.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-13 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on Observation, Interview and Record review, the facility failed to provide lower extremity Range of Motion programing to a resident with limited joint mobility and a diagnosis of Foot Drop for one of one resident (R61) reviewed for limited range of motion in the sample of 35. Findings include: The facility's Rehabilitative Nursing Care policy, dated 4/2007, documents Rehabilitative nursing care is provided for each resident admitted . General rehabilitative nursing care is that which does not require the use of a qualified professional therapist to render such care. Nursing personnel are trained in rehabilitative nursing which is developed and coordinated through the resident's care plan. The facility's Range of Motion policy, dated 1/31/2018, documents The facility will ensure that a resident who enters the facility without a limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable. The facility will ensure that a resident with a limited range of motion…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-13 · 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 safely transfer 1 resident (R27) of 6 residents reviewed for transfers in a sample of 35. Findings include: The Gait Belt policy dated 4/13 documents Gait belts are used to help prevent injury of staff or resident during transfers and ambulation. 1. Gait belts should be used by all staff when ambulating or transferring a resident with an unsteady gait. 9. To transfer the resident, assist to standing by holding the belt at the waist and pivot the resident to the chair. On 6/10/24 at 1:46 PM, V10/R27's Power of Attorney stated that there are times when R27 has bruises on her arms and the facility said it happened when transferring R27. On 6/12/24 at 12:38 PM, V2/Director of Nursing (DON) stated that the staff are to use a gait belt and not hold on to a resident's arm when doing a transfer. R27's current computerized medical record, documents R27 is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Vascular Dementia,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-13 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to document justification for the use of duplicative antidepressant therapy for one of five residents (R1) reviewed for psychotropic medications in the sample of 35. Findings include: The facility's Psychotropic Medications Policy (undated) documents the following: This facility shall ensure that residents do not receive psychotropic drugs unless such therapy is necessary to treat a specific condition is diagnosed by the attending physician or psychiatric consultant. Attempts will be made to reduce or discontinue use of such medications whenever possible without compromising resident's health and safety, ability to function appropriately, or the safety of others. R1's current Physician's Orders document the following medication orders: Bupropion (antidepressant) 200 milligrams by mouth daily; and Paroxetine (antidepressant) 40 milligrams by mouth twice daily. On 06/13/24 at 01:30 PM, V3 (Registered Nurse) stated she is the individual that manages psychotropic medications for the residents in the facility. V3 stated that R1 is…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-04 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to observe ingestion of medication for one resident (R3) during observation of a routine medication pass. Findings Include: The Facility's Medication Administration Policy dated 01/2018 documents Medications shall be prepared and administered only to residents for whom they were ordered, by the same licensed nurse. Setting up doses for more than one (1) scheduled administration is not permitted. No medication may be returned to its original container once removed from the container. The Facility's Medication Administration Policy also documents Residents to indicate a desire to self administer medications will be assessed, using an assessment tool, by the interdisciplinary care plan team and information given to the physician for approval. Residents will be allowed to self administer medications only when the attending physician has written an order for self administration. The use and response to this medication will be monitored by licensed nurses. On 9/4/23 at 8:45 AM while V7 (RN) was preparing medications 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-05-25 · tag F0806 — failed to honor food preferences — widespread
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview the facility failed to consistently offer substitutes at mealtimes. This failure has the potential to affect all 56 residents who reside in the facility. Findings Include: The Facility's undated Food Substitution Policy documents Resident may be offered a planned substitute entrée if desired. An alternate menu will be posted in addition to the planned menu. On 5/22/23 at 11:00 AM after V6 (Dietary Aide) listed the lunch options R208 stated he did not like either option. V6 stated I need you tell me which one you would rather. On 5/22/23 at 11:05 AM V6 (Dietary Aide) stated Sometimes we have mashed potatoes as a substitute but not today, and those are usually only offered to the lactose intolerant residents. On 5/23/23 at 10:00 AM during resident group meeting R26, R34, R35, R37, R38, R40 and R108 all stated it can be difficult to get a substitute. On 5/23/23 during group R40 stated The food is gross; you get a choice of two things. If you don't like one of the two things, you just eat the sides. On 5/23/23 during group R180 stated I…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-05-25 · 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 store dry goods in a clean and sanitary manner. This failure has the potential to affect all 56 residents who currently reside in the facility. Findings Include: The Facility's undated Storage of Dry Goods/Foods Policy documents non-refrigerated foods, disposable dishware and other dry goods are stored in a clean, dry area which is free from contaminants. The Storage of Dry Goods/Foods Policy documents Plastic containers with tight-fitting lids will be used for storing flour, sugar, bulk cereal, dried vegetables, etc. Opened products are labeled, dated with the use by date and tightly covered to protect against contamination including from insects and rodents. On 5/22/23 at 9:10 AM, In the kitchen dry storage room there were 8 boxes full of various dry food stuffs sitting directly on the floor and two paper bags full of loaves of bread sitting directly on the floor. V5 (Dietary Manager) stated We got our delivery on Friday (5/19/23) and we are still working on getting it put away. On 5/22/23 at 9:20 AM 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-25 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to revise a smoking care plan for one (R31) of 18 residents reviewed for care planning in the sample of 27. Findings include: The facility's Care Plan policy and procedure, dated April 2015, documents 3. Each resident's Comprehensive Care Plan has been designed to: a. Incorporate identified problem areas. b. Incorporate risk factors associated with identified problems. c. Build on resident's strengths. d. Reflect treatment goals and objectives in measurable outcomes. e. Identify the professional services that are responsible for each element of care. f. Aid in preventing or reducing declines in the resident's functional status and/or functional levels. g. Enhance the optimal functioning of the resident by focusing on a rehabilitative program, as needed. h. Be respectful of a resident's health beliefs, practices and cultural and linguistic needs. i. Reflect the resident's needs and preferences and align with the resident's cultural identity. 5. Care Plans are revised as changes in the resident's condition…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-25 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to perform a GDR (Gradual Dose Reduction) for one resident (R1), document a diagnosis and clinical indication to warrant the use of an antipsychotic and comprehensively evaluate and assess for underlying conditions or stressors, non-pharmacological behavioral interventions, and psychotropic drug use prior to administering a PRN (as needed) antipsychotic for one resident (R26), and document clinical indications to justify the increase of an antipsychotic for one resident (R39), of four residents reviewed for anti-psychotic medication use in the sample of 27. Findings include: The Psychotropic Medication Policy dated 5/2017, documents This facility shall ensure that residents do not receive psychotropic drugs unless such therapy is necessary to treat a specific condition diagnosed by the attending physician or psychiatric consultant. Attempts will be made to reduce or discontinue use of such medications whenever possible without compromising…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-25 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to serve physician ordered supplements for three of six residents (R3, R12, R39) reviewed for nutrition in the sample of 27. Findings include: The facility's Therapeutic Diets policy, dated 4/2007, documents, Therapeutic diets shall be prescribed by the attending physician. A therapeutic diet must be prescribed by the resident's attending physician. The physician's diet order should match the terminology used by Food services. The Food Services Manager will establish and use a tray identification system to ensure that each resident receives his or her diet as ordered. Residents on therapeutic diets will not receive extra or reduced portions or modifications that are not part of the diet, unless approved by the attending physician in conjunction with the clinical dietitian. 1. On 05/22/23 at 12:44 PM, R3 was served turkey salad, capri vegetables, and peach cobbler. R3 was not served a high protein high calorie frozen supplement. R3 stated, I don't get an ice cream cup with my lunch. R3's Physician Orders, dated…

    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

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to ATIED ASSOCIATES — 12 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 51.8-0.8 vs chain
Health inspection 2 of 52.2-0.2 vs chain
Staffing 1 of 51.8-0.8 vs chain
Quality measures 3 of 53.2-0.2 vs chain
The other 11 homes this chain runs (chain average 1.8★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
RAY, SHERWINIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF60%since 08/01/2015
BAKER, SHELBYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/23/2023
DIXON, WILLIAMIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2020
ATIED ASSOCIATES LLCOrganizationADP OF THE SNFsince 08/01/2015
EXTENDED CARE CLINICAL LLCOrganizationADP OF THE SNFsince 08/01/2015
EXTENDED CARE CONSULTING LLCOrganizationADP OF THE SNFsince 08/01/2015
SHIFTKEY LLCOrganizationADP OF THE SNFsince 03/01/2023

CMS files one row per role, so the 10 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$6.0M
Net patient revenuemost recent cost report
-13.3%
Operating marginrevenue minus expenses
$799K
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 72%Medicare 9%Other / private 20%

About 72% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $799K paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$313per resident / day
operating cost
$9,521per month
≈ monthly operating cost
$276per day
avg. revenue, all payers

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

What families pay in IL

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145488. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-09, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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