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Doctors Nursing & Rehab Center

1201 Hawthorn Road, Salem, IL 62881 · For profit - Limited Liability company · 120 certified beds · (618) 548-4884 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0602) — most recent Apr 20261 immediate-jeopardy citation1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$107,564 in federal fines
Insights

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

Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Apr 2026
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0605, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (34) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $107,564 in federal fines (most recent 2025-08-12)
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (2/5)

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 1 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
126 Cross Creek Blvd · (618) 548-3769 · Call to confirm hours
Pharmacy
1022 W Main St · (618) 548-5300 · Call to confirm hours
Grocery
1401 W Main St · (618) 548-0112 · Call to confirm hours
Park
(618) 548-2222 · Typically dawn to dusk
Place of worship
FCC Salem<0.1 mi
1200 W Boone St · (618) 548-0867

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 2 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 1 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.

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

Overall rating1★
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 increased16.9%13.4%15.4%typical
Long-stay residents who lose too much weight17.1%6.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.9%0.9%0.9%typical
Long-stay residents with a urinary tract infection0.5%1.5%2.0%better
Long-stay residents with depressive symptoms42.9%54.2%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.5%0.1%0.1%worse
Long-stay residents with falls causing major injury6.6%3.1%3.3%worse
Long-stay residents whose ability to walk worsened27.2%14.3%16.1%worse
Long-stay residents on antianxiety or hypnotic medication34.4%18.3%18.9%worse
Long-stay residents given the seasonal flu vaccine97.1%91.8%95.3%typical
Long-stay residents with pressure ulcers7.9%4.8%4.7%worse
Long-stay residents with worsening bladder/bowel control24.8%20.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table17.0%21.7%17.1%typical
Short-stay residents who newly got an antipsychotic medication4.3%2.2%1.4%worse
Short-stay residents given the seasonal flu vaccine66.0%63.1%79.4%worse
Short-stay residents rehospitalized after admission13.7%26.1%22.6%better
Short-stay residents with an outpatient ER visit26.1%13.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.042.021.67better
Long-stay outpatient ER visits per 1,000 resident days5.182.221.80worse

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.

41.5% 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 78 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

41.5%U.S. median 51.5%
Got home and stayed home
11.4%U.S. median 10.7%
Went back to hospital
34.1%U.S. median 56.6%
Met the expected recovery
0.18U.S. median 0.31
Therapy hours / resident / day
0.10hours / resident / day
Physical therapy
0.06hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 34.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 44 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 0.18 therapist hours per resident per day in 2026Q1 — more than 18% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF41.5%CMS range 32.6–50.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.4%CMS range 8.2–18.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge34.1%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge29.6%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 discharge27.3%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 discharge100.0%98.7%Oct 2024–Sep 2025CMS 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 stay1.7%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 worsened6.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.2%CMS range 3.5–10.97.1%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

0.52
RN hours/ resident / day
0.63
LPN hours/ resident / day
2.25
Aide hours/ resident / day
3.40
Total nurse hours/ resident / day
0.55
RN hoursweekends
53.3%
Total nursing turnover
60.0%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 48.7 residents a day — about 41% occupied, or roughly 71 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 3.40 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.52 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.25 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.27 hrs/resident/day on weekends vs 3.45 on weekdays — 5% thinner on weekends. RN hours go from 0.51 to 0.55 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 53% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

8
deficiencies at the latest standard inspection (2026-03-13)
1
at the previous standard inspection (2025-02-27)

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.

34 citations, most serious first. The 14 most serious are shown; the remaining 20 are one tap away and print in full.

  • Immediate jeopardy · J2026-02-10 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow physician's orders and monitor resident's declining conditions for 2 of 3 residents (R1 and R3) reviewed for resident death in a sample of 8. A. This failure resulted in worsening of R1's infection of bilateral lower leg venous wounds causing sepsis and subsequent death. B. This failure resulted in exacerbation of R3's congestive heart failure resulting in hospitalization and subsequent death. This failure resulted in an Immediate jeopardy, which was identified to have begun on:A. [DATE] when the facility failed to follow physician's orders for antibiotics for R1's infection of venous stasis ulcers. This failure resulted in R1 developing sepsis leading to R1's death on [DATE].B. [DATE] when the facility failed to complete ordered lab work and administer medications as ordered for R3. This failure resulted in worsening of R3's Congestive Heart Failure causing respiratory failure leading to R3's death on [DATE]. V1, Administrator, V2, Director 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
  • Actual harm · Hcited before2025-08-12 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide Heat, Ventilation, and Air Conditioning (HVAC) systems to maintain a comfortable temperature and failed to maintain flooring that was clean and free from damage. This failure resulted in R1 and R6 experiencing difficulty breathing and R5 and R7 experiencing difficulty sleeping, resulting in significant discomfort. This failure has the potential to affect all 58 residents residing in the facility.Findings include:1. On 7/30/25 at 10:03 AM, a digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method and was accurate within +/- 2 degrees Fahrenheit. R1's Resident Face Sheet documented an admission date of 12/12/24 and included diagnoses of morbid obesity, chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease, and congestive heart failure. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS)…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2024-02-26 · 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 transport 1 (R1) of 3 residents reviewed for accidents. This failure resulted in R1 receiving a fracture to R1's fifth and sixth cervical vertebrae and right radius. This past noncompliance occurred between 1/29/2024 - 2/01/2024. The findings include: R1's face sheet documents R1 was admitted to the facility on [DATE], with diagnoses of Unspecified fracture of shaft of right tibia, subsequent encounter for closed fracture with routine healing, Unspecified fracture of the lower end of right radius, subsequent encounter for closed fracture with routine healing, Other nondisplaced fracture of fifth cervical vertebra, subsequent encounter for fracture with routine healing, Unspecified fracture of right femur, subsequent encounter for closed fracture with routine healing, Other nondisplaced fracture of sixth cervical vertebra, subsequent encounter for fracture with routine healing, Unspecified fracture of shaft of right fibula, subsequent encounter…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Actual harm · Gcited before2023-08-25 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents are free from staff to resident abuse for one resident of four residents (R3) reviewed for abuse in the sample of 4. This failure resulted in R3, during care on 7/6/23, experiencing physical pain and emotional distress with continued feelings of intimidation, fear, sadness, anxiety and helplessness. Findings include: R3's Face Sheet documented an admission date of 3/7/23, and diagnoses including Quadriplegia, Tracheostomy, Pressure Ulcer of the Sacrum, Diabetes Type 2, Morbid Obesity, Hypertension, Anxiety Disorder, Insomnia, Unspecified Depressive Episodes, and Polyneuropathy. R3's Minimum Data Set, dated [DATE], documented R3 has no deficits in cognition, is totally dependent on at least two staff for transfers, bed mobility, dressing, eating, and toileting. Nurses Note, dated 7/6/23 at 11:54am, authored by V4, Registered Nurse, documented, Resident accused CNA (Certified Nursing Assistant) of being rough while completing care. 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2026-04-15 · tag F0725 — failed to have enough nursing staff — widespread
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure staffing is sufficient to meet the needs of the residents timely. This has the potential to affect all 50 residents currently residing at the facility. Findings Include:The facility Resident Roster dated 4/8/26 documents 50 residents currently reside at the facility.1.R1's Resident Face Sheet with a print date of 4/11/26 documents R1 was admitted to the facility on [DATE] and discharged from the facility on 4/8/26, with diagnoses that include heart failure, age related physical disability, and diabetes.R1's MDS (Minimum Data Set) dated 2/27/26 documents a Brief Interview for Mental Status) score of 11, indicating R1 has a moderate cognitive deficit. This same MDS documents R1 is dependent on staff for toilet hygiene.R1's current Care Plan documents a Problem area with a start date of 2/24/26 of, Resident: admitted for skilled care. I require a Baseline Care Plan identifying care needs, risks, strengths, and goals within the first 48 hours. This…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-15 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure call lights were answered timely for 2 of 4 (R1 and R2) residents reviewed for call lights in the sample of 14.Findings Include:1.R1's Resident Face Sheet with a print date of 4/11/26 documents R1 was admitted to the facility on [DATE] and discharged from the facility on 4/8/26, with diagnoses that include heart failure, age related physical disability, and diabetes.R1's MDS (Minimum Data Set) dated 2/27/26 documents a Brief Interview for Mental Status) score of 11, indicating R1 has a moderate cognitive deficit. This same MDS documents R1 was dependent on staff for toilet hygiene.R1's current Care Plan documents a Problem area with a start date of 2/24/26 of, Resident: admitted for skilled care. I require a Baseline Care Plan identifying care needs, risks, strengths, and goals within the first 48 hours. This Problem area includes the intervention with a start date of 2/24/26 of, Bowel and Bladder: I am incontinent for urine and toileting. I 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-15 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure comfortable water temperatures for 3 of 4 residents (R1, R2, and R14) residents reviewed for environment in the sample of 14.Findings Include: 1.R1's Resident Face Sheet with a print date of 4/11/26 documents R1 was admitted to the facility on [DATE] and discharged from the facility on 4/8/26, with diagnoses that include heart failure, age related physical disability, and diabetes.R1's MDS (Minimum Data Set) dated 2/27/26 documents a Brief Interview for Mental Status) score of 11, indicating R1 has a moderate cognitive deficit. This same MDS documents R1 is dependent on staff for bathing.R1's current Care Plan documents a Problem area with a start date of 2/24/26 of, Resident: admitted for skilled care. I require a Baseline Care Plan identifying care needs, risks, strengths, and goals within the first 48 hours. This Problem area includes the intervention with a start date of 2/24/26 of, Activities of Daily Living: Overall 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-15 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect 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 residents were free from misappropriation of medications for 3 of 3 (R3, R4, and R5) residents reviewed for abuse in the sample of 14.This past non-compliance occurred between 3/27/26 and 4/1/26.Findings Include:The Long Term Care Facility and IID (Individuals with Intellectual Disabilities) -Serious Injury Incident Report dated 3/28/26 documents under Detailed Incident Summary, Administration was notified of possible drug diversion at the facility regarding (R3's) oxycodone. It was discovered that (R3's) narcotic card had been tampered with and the medication in the card was metoprolol and not oxycodone. Investigation continued and MD (physician), POA (power of attorney) and local police were notified of the investigation. Nurses currently on shift were immediately drug tested and were negative. Call was made to (V7/Registered Nurse-RN) for interview and drug test. (V7) did not answer the call so the DON (Director of Nurses/V2) made arrangements…

    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 · Past Non-Compliance
  • Potential for harm · D2026-04-15 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure incontinence care was provided timely for 2 of 4 (R1 and R2) residents reviewed for activities of daily living (ADL) in the sample of 14.Findings Include:1. R1's Resident Face Sheet with a print date of 4/11/26 documents R1 was admitted to the facility on [DATE] and discharged from the facility on 4/8/26, with diagnoses that include heart failure, age related physical disability, and diabetes.R1's MDS (Minimum Data Set) dated 2/27/26 documents a Brief Interview for Mental Status) score of 11, indicating R1 has a moderate cognitive deficit. This same MDS documents R1 is dependent on staff for toilet hygiene and has occasional urinary and bowel incontinence.R1's current Care Plan documents a Problem area with a start date of 2/24/26 of, Resident: admitted for skilled care. I require a Baseline Care Plan identifying care needs, risks, strengths, and goals within the first 48 hours. This Problem area includes the intervention with a start date 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 · D2026-04-15 · 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 a urinalysis was obtained timely for 1 of 3 (R1) residents reviewed for urinary tract infections in the sample of 14.Findings Include:1.R1's Resident Face Sheet with a print date of 4/11/26 documents R1 was admitted to the facility on [DATE] and discharged from the facility on 4/8/26, with diagnoses that include urinary tract infections.R1's MDS (Minimum Data Set) dated 2/27/26 documents a Brief Interview for Mental Status) score of 11, indicating R1 has a moderate cognitive deficit.R1's current Care Plan documents a Problem area with a start date of 2/24/26 of, Resident: admitted for skilled care. I require a Baseline Care Plan identifying care needs, risks, strengths, and goals within the first 48 hours. This Problem area includes the intervention with a start date of 2/24/26 of, Bowel and Bladder: I am incontinent for urine and toileting. I am incontinent of bowel and toileting. I require assistance to remain dry and clean. I use briefs, pads…

    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 before2026-04-15 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure medications were crushed prior to administration for 1 of 3 (R1) residents reviewed for pharmacy services in the sample of 14.Findings Include:R1's Resident Face Sheet with a print date of 4/11/26 documents R1 was admitted to the facility on [DATE] and discharged from the facility on 4/8/26, with diagnoses that include dysphagia, oropharyngeal phase, heart failure, age related physical disability, and diabetes.R1's MDS (Minimum Data Set) dated 2/27/26 documents a Brief Interview for Mental Status) score of 11, indicating R1 has a moderate cognitive deficit. This same MDS documents R1 is dependent on staff for bathing.R1's current Care Plan does not document a Problem area related to medication administration.R1's Physician Order Report dated 2/24/26 through 3/30/26 documents an order dated 3/10/26 of Diet: Regular solids with Nectar liquids, add household shakes to all meals and an order dated 2/24/26 of May crush medications- do not crush…

    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 · Ecited before2026-03-13 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed to ensure there was hot water for showers and personal care for the 21 residing on the 200 and 300 halls. The Findings Include: On 3/11/26 at 1:00 PM, a digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method and was accurate within +/_ 2 degrees Fahrenheit. On 03/11/2026 at 1:12 PM, R10 who was alert and oriented, stated her biggest concern is that the facility does not have hot water. R10 stated when the CNA's (Certified Nurse Assistants) have to clean her up the water is freezing cold. R10 stated it is awful to get your butt wiped with a cold washcloth. On 3/11/26 at 1:15 PM, R23 who alert and oriented, stated that he never has hot water in his sink in his room that he uses to wash up with at night and in the morning. R23 stated that the shower room water temperature is better, but not always hot. On 3/11/2026 at 1:17 PM, the water temperature was taken at the sink…

    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 · Ecited before2026-03-13 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to provide sufficient staff to meet residents needs in a timely manner. These failures have the potential to affect all 10 residents residing on the 100 hall.The Findings include On 3/11/26 at 11:40AM, V30 (Family Member) stated that in the evening hours and on weekends it is very hard to get assistance from staff with call lights. V30 stated she has to walk the halls to find staff to assist R23. On 3/11/26 at 2:00 PM, during the resident council R1 who was alert to person, place and time and R5 who was alert to person, place and time both stated that evening time it is hard to get someone to answer your call light. R1 resides on the 100 hall.On 03/12/2026 at 8:54 AM, V6 (Certified Nursing Assistant/CNA) stated, that residents need to be turned/repositioned every 2 hours or as needed. V6 also stated that, or as often as I can by myself today when she was asked how often she does bed checks. V6 stated, the next CNA comes in at 10 AM and if she hasn't found help to assist the residents who require 2 people they will get to those…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-03-13 · tag F0761 — failed to label and store drugs safely — pattern
    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 dispose of expired stock medical equipment, expired resident and stock medications, and failed to label medications with residents' names, and document the date opened on multi-use vials of medications for 4 of 6 residents (R5, R12, R26, and R44 ) reviewed for medication storage in the sample of 26.Findings include:On 3/11/26 at 10:55 AM the facility's medication storage room was reviewed with V3, Assistant Director of Nursing. V3 opened the medication refrigerator and pulled out 5 bags that each contained a swab and a lab collection tube. Each swab documented the expiration date of 10/2024. There was one unopened vial of Daptomycin with no name on label and an expiration date of 1/12/25. There was an unopened vial of Humulin R insulin with the expiration date of 11/21/25. There were 2 boxes of Arformoterol nebulizer solution with R26's name on the labels, one box had expiration date of 1/19/26 and the other box had the expiration date of 12/1/24. There were 2 boxes of Formoterol nebulizer solution with R26'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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 20 citations
  • Potential for harm · D2026-03-13 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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 restraint assessments for 2 (R3, R7) of 2 residents reviewed for physical restraints in the sample of 26. The Findings Include: 1.R3's Face Sheet documented an admission date of 2/10/2026 and included diagnoses of cerebral infarction, dependence on respirator, chronic respiratory failure with hypercapnia, and acute pulmonary disease. R3's Minimum Data Set (MDS) with assessment reference date as 2/16/2026 documents no Brief Interview for Mental Status score because resident is rarely/never understood, indicating significant cognitive impairment. This same assessment documented under Section P0-Restraints and Alarms of limb restraint is used less than daily. R3's Care Plan documented a focus area of physical restraints; resident is at risk for decline related to use of physical restraint - hand mitt right hand with an intervention of assessing and documenting the need for a restraint. R3's Physician Orders dated 2/18/2026 documented hand mitt as needed to prevent pulling/removal of tubes, release every…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-13 · 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

    Based on interview and record review the facility failed to ensure that residents are free from unnecessary medication 1 of 5 residents (R2) reviewed for unnecessary medications in a sample of 26. The Findings Include:R2's face sheet indicates an admission date of 11/7/24 and also includes the following diagnosis: anxiety disorder and depression. R2's current physician order sheet for March 2026 includes the following medications: lorazepam 0.5 milligram (mg) once day per gastric tube as needed for anxiety. This order has a start date of 1/09/2026 with no end date. R2's behavior tracking for the last 3 months has no behaviors listed. R2's medication administration record for the last three months list that R2 received lorazepam 1/15/26-1/20/26, 2/2/25, 2/3/26, 2/5/26, 2/9/26-2/12/26, 2/15/26-2/18/26, and 2/24/26-2/26/26.There was no documentation found in R2's record to indicate a reason for R2's Lorazepam to be extended beyond 14 days.On 3/13/2026 at 12:30 PM, V32 (Regional Director of Clinical Services) stated, that she will continue to work with the physicians to ensure that they…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-13 · 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 interview, observation, and record review the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion for 1 (R9) of 12 residents reviewed for position and mobility in the sample of 26. The Findings Include:R9's resident face sheet documents an admission date of 10/12/2018. This same document includes the following diagnoses: Parkinsonism, symptomatic epilepsy, partial seizures, hypotension, anemia, asthma, contracture of the right hand, and chronic pain. R9's most recent quarterly MDS (Minimum Data Set) dated 12/30/2025 documents section C, that R9 has a BIMS (Brief Interview of Mental Status) of 15, indicating that R9 is cognitively intact. Section GG documents for functional limitation in range of motion that R9 has an impairment on one side for upper extremity. Section GG for self-care documents that R9 is Dependent for toileting, lower body dressing, putting on taking off footwear, substantial / maximal assistance for shower / bathe, upper body dressing, and personal…

    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 · D2026-03-13 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    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 interview and record review the facility failed to ensure that meals served were served at palatable temperature for 3 of 3 (R1, R5 and R23) residents reviewed for palatability in a sample of 26. The Findings Include: During the resident council meeting held on 3/11/26 at 2:00 PM, R1 and R5 both stated that the evening meals are cold and often times they just eat it cold rather than regularly asking for it to be reheated. R1 is the resident council president and was alert to person place and time. R5 stated he attends resident council meetings regularly and was alert to person place and time. On 3/11/26 at 11:40 AM, R23 who was alert to person, place and time stated his family often brings in food for him at dinner so he doesn't have to eat cold food.On 3/12/26 at 12:45 PM, R5 stated that the cold food in the evening has been brought up in resident council meetings regularly. Review of resident council minutes for the last 6 months showed no concerns for dietary and/or cold food. Review of grievance log for last 6 months was reviewed and no grievances logged for cold food…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-13 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow infection control practices for 3 (R1, R2, and R3) of 12 residents reviewed for infection control in the sample of 26. The Findings Include:Facility policy titled Cleaning of Durable Medical Equipment with a revision date of 01/18/2021 documented under section titled Policy: All Durable Medical Equipment will be disinfected with appropriate disinfectant between resident uses. Including but not limited to blood glucose monitoring machines, pulse oximeters, thermometers, etc. Under Section titled procedure, to clean, disinfect, and deodorize in one step: wipe surface with towel until completely wet. Allow to remain wet for one minute at room temperature. Wipe dry or allow to air dry.On 03/10/2026 at 11:16 AM, V3 (Licensed Practical Nurse / Assistant Director of Nursing) gathered blood glucose machine, lancet, alcohol wipe and micro kill wipe and placed on disposable tray. V3 sanitized hands and placed gloves on. V3 knocked on the door…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2026-02-18 · tag F0725 — failed to have enough nursing staff — widespread
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide sufficient staff to meet residents needs in a timely manner. These failures have the potential to affect all 47 residents living in the facility.The findings include: 1.R2's Face Sheet dated 02/17/26, documents an admission date of 03/19/21 with diagnoses in part of polyosteoarthritis, morbid obesity, pain in left leg, malignant neoplasm of endometrium, chronic obstructive pulmonary disease, pressure ulcer of sacral region, pain in right knee and unspecific convulsions. R2's MDS (Minimum Data Set) dated 02/04/26 documents in Section C, a BIMS (Brief Interview for Mental Status) score of 15 which indicates R2 is cognitively intact. Section GG documents toileting as dependent and turning and repositioning as substantial/maximal assistance. Section M documents under current number of unhealed pressure ulcers/injuries at each stage as 1 unstageable. R2's Care Plan with an edited date of 02/05/26 documents a problem area of resident is incontinent 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-10 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to adhere to infection control protocols and failed to follow physician orders for wound care for 1 of 1 resident (R4) reviewed for pressure ulcers in a sample of 9. Findings include:R4's Face Sheet documents an admission date of 12/8/25 with diagnoses including in part muscular dystrophy, muscle wasting and atrophy, muscle weakness, osteomyelitis of vertebra sacral and sacrococcygeal region, paresthesia of skin, underweight, and multiple sclerosis. R4's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) of 15, indicating R4's cognition is intact. In Section M it documents under Determination of Pressure Ulcer/Injury Risk; A. R4 has a pressure ulcer/injury, a scar over boney prominence, or a non-removeable dressing/device. Under Unhealed Pressure ulcer/Injuries it documents R4 has a one or more unhealed pressure ulcers/injuries, and under Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage it…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-12 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to thoroughly investigate an allegation of staff to resident verbal abuse for 1 of 5 residents (R2) reviewed for abuse in the sample of 6.Findings include:R2's Face sheet documented an admission date of 08/16/2025 to the facility. Diagnoses listed include: chronic atrial fibrillation, congestive heart failure, systemic lupus, osteoporosis, hypotension, gastro-esophageal reflux disease, low back pain, shortness of breath, chronic kidney disease stage 4, and aneurysm of ascending aorta.R2'S Minimum Data Set (MDS) dated [DATE] documented that R2 has a Brief Interview for Mental Status (BIMS) of 14, indicating R2 was cognitively intact.R2's Nurse note documented on 09/15/2025 that a call placed to local police department and physician to inform of abuse allegation. R2's nurse notes do not document anything further regarding R2's allegation of verbal abuse.A form titled State of Illinois Department of Public Health Long - term Care Facility and IID Serious…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-08-12 · 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 maintain a temperature of less than 70 degrees Fahrenheit in the dietary dry storage area in accordance with facility policy. This failure has the potential to affect all 58 residents residing in the facility.Findings include:On 7/30/25 at 10:03 AM, a digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method and was accurate within +/- 2 degrees Fahrenheit. On 7/30/25 at 11:08 AM, V5 (Dietary Manager) said the dietary dry storage area did not have a functioning Heating, Ventilation, and Air Conditioning (HVAC) unit and had been very hot since the start of summer 2025. Using the calibrated thermometer, the ambient air temperature in the dietary dry storage area was observed to be 90.6 degrees Fahrenheit.On 7/30/25 at 12:06 PM, V4 (Maintenance Director) said he had notified the HVAC company of the HVAC system not functioning in the dietary dry storage area and was told the HVAC company would not be coming to the facility until the facility…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-08-12 · tag F0835 — failed to run the facility competently — widespread
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    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 the facility was administered and operated in a manner to ensure the safety and overall wellbeing for all 58 residents residing in the facility.Findings include:On 8/1/25 at 2:26 PM, V1 (Former Administrator) said he had emailed and called corporate several times about the HVAC (Heating, ventilation, and Air Conditioning) units and PTAC (Packaged Terminal Air Conditioner) systems not working but didn't hear anything back from them. V1 said he did not have the authority to change the HVAC units, that was a corporate decision. V1 said he had been asking corporate to fix the HVAC unit in the dietary dry storage area for 1 year and 1 month prior to this investigation. V1 said he had notified corporate of the dining room floors needing to be replaced but had not been given approval to fix them.On 7/30/25 at 12:06 PM, V4 (Maintenance Director) said he had been told by the HVAC company they would not return to the facility to fix the HVAC units until their bill had been paid from December 2024. V4 said he had requested…

    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 · D2025-08-12 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a functioning call light system for 3 (R2, R3, and R4) of 6 residents reviewed for resident call system in the sample of 6.Findings include:R2's Resident Face Sheet documented an admission date of 2/21/18 and included diagnoses of hemiplegia following cerebral infarction, vascular dementia, and need for assistance with personal care. R2's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment.R3's Resident Face Sheet documented an admission date of 8/23/24 and included diagnoses of chronic respiratory failure and history of cerebral infarction. R3's MDS dated [DATE] documented a BIMS score of 9, indicating moderate cognitive impairment.R4's Resident Face Sheet documented an admission date of 12/21/23 and included diagnoses of other motor neuron disease, respiratory failure, and chronic pain. R4's MDS dated [DATE] documented a BIMS…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-02-27 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) and Standard Precautions for 5 (R35, R319, R33, R15, and R31) of 9 residents reviewed for Infection Control in a sample of 43. Findings include: The facility policy titled Isolation Precautions/ Enhanced Barrier Precautions (EBP) dated 4/1/2024 states Policy: It is the policy of [NAME] Healthcare to make every effort to prevent the spread of infection in the facility. Standard Precautions require the health care worker (HCW) to estimate the degree of risk associated with a given task and plan for appropriate personal protective equipment. Enhanced Barrier Precautions (EBP) is used in combination with Standard Precautions and expand the use of Personal Protective Equipment (PPE) to donning of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs (Multi Drug Resistant Organisms) to staff hands and clothing. EBP will be used for any resident…

    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 · Fcited before2024-12-12 · tag F0584 — failed to keep a safe, clean, comfortable home — widespread
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to maintain comfortable temperatures in the facility for 9 (R1-R9) residents living in the facility. The facility also failed to maintain ceiling tiles and HVAC (Heating Ventilation and Air Conditioning) Units in a safe and sanitary condition. This failure has the potential to affect all 74 residents residing in the facility. The findings include: 1. On 12/6/24 at 10:12 AM, R1 was lying in bed under 5 blankets with another blanket covering his feet. R2 (R1's) roommate was sitting in his wheelchair in their room dressed and wearing his coat. R2 said it had been really cold in their room and that was why R2 was wearing his coat. V7 (Housekeeping Supervisor) was asked to turn on the heating unit in R1 and R2's room. When V7 pushed the red button on the heating unit a small amount of cold air started blowing out of the heating unit. V7 said she did not know if R1 and R2's heating unit was working. R1 and R2's heating unit did not have a knob to adjust the temperature, only the small metal piece the temperature…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-08 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to follow the menu and diet orders for 6 of 6 (R2, R3, R5, R6, R7 and R8) residents reviewed for menus meeting resident needs in the sample of 8. The Findings Include: On 10/3/2024 at 11:53 AM, R5 who was alert and oriented to person, place and time, stated he did not get any eggs or double meat with his breakfast this morning. R5 stated, today he had one biscuit and gravy. R5 stated, he does not normally get eggs or double meats for breakfast at all. On 10/08/2024 at 7:26 AM during breakfast meal observation, V14 (Cook) stated, they are serving biscuits and gravy, super cereal, and oatmeal for breakfast today. V14 stated, the kitchen had run out of meats and eggs for breakfast this morning. V14 stated, the delivery truck will be in around 11:30 AM today with those items. V14 stated, normally residents who are supposed to have eggs or double protein at breakfast will get a yogurt or one teaspoon of peanut butter added to cereal as a substitute for not getting eggs or a meat for breakfast. V14 stated, R2, R3, R5,…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-06-28 · tag F0807 — failed to offer suitable drinks — pattern
    Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, observations, and record review the facility failed to provide water and other fluids to meet the residents needs and preference for 18 out of 47 residents (R1, R2, R3, R4, R6, R7, R8, R9, R10, R15, R20, R22, R24, R26, R30, R33, R37, and R46) reviewed for hydration in a sample of 47. The findings include: On 6/26/2024 at 10:08 AM, R7 was observed sitting in her room visiting with family. There was no waster pitcher or other fluids available in R7's room. At 12:05 PM on the same date, there were still no water pitcher or other fluids available observed in R7's room. On 6/26/2024 at 11:40 AM, there was no observation of a water pitcher or any other liquids to drink in R3's room. R3 was asked where her water pitcher was and she stated, I don't have one. R3 stated I drink what I get on my meal trays normally. R3 is alert and oriented at this time. On 6/26/2024 9:59 AM and 12:00 PM, R4 was observed siting in her room. There was no water pitcher observed in R4's room at the time of the observations. On 6/26/2024 at 12:05 PM, R1 is an alert and oriented male sitting up…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-26 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to reorder regularly scheduled pain medication in a timely manner for 1 (R5) of 3 residents reviewed for pharmacy services. The findings include: R5's face sheet documents R5 was admitted to the facility on [DATE], with diagnoses of Morbid (severe) obesity due to excess calories, Other chronic pain, Other stimulant abuse, uncomplicated, 2/13/2024, and Urinary tract infection, site not specified. R5's Minimum Data Set (MDS), dated [DATE], documents Section C, a Brief Interview for Mental Status (BIMS) score of 15, indicating R5 is cognitively intact. Section GG, Functional Abilities and Goals, documents R5 requires setup/clean-up assistance with eating, oral hygiene, is dependent with toileting hygiene, lower body dressing, putting on/off footwear, transfers, requires substantial/maximal assistance with showering, bed mobility, and partial/moderate assistance with upper body dressing, personal hygiene. Section J, Pain management, documents R5 receives…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-13 · 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 interview and record review, the facility failed to keep a resident free from abuse for 1 of 1 resident (R2) reviewed for abuse in the sample of 11. Findings include: On 12/11/2023 at 1:00PM, R2, who was alert to person place and time, said on the evening of 11/27/23, R1 kept asking R2 for some change, and when she told R1 no, R1 became mad and hit the back of R2's head with R1's hand. R2 said V8 (Licensed Practical Nurse/LPN) and R6 both witnessed the incident. R2 said staff immediately separated R1 from the other residents and quickly helped her. R2 said she was not hurt, however, she intended to press charges against R1 for hitting her. R2 said she was sent to the local emergency room for evaluation as a precaution, and all the test results came back fine. R2 said she was not scared of R1 and felt safe at this facility. R2 said she has not really had any trouble with R1 before this incident. On 12/11/2023 at 2:00PM, V8 (LPN) said she witnessed R1 hit R2 on 11/28/2023. V8 said R1 and R2 have never had any problems before that she knew of. V8 said R1 had asked R2 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-25 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of staff to resident physical and emotional abuse to IDPH (the Illinois Department of Public Health) and local law enforcement for one resident (R3) of four residents reviewed for abuse in the sample of 4. Findings include: R3's Face Sheet documented an admission date of 3/7/23, and diagnoses including Quadriplegia, Tracheostomy, Pressure Ulcer of the Sacrum, Diabetes Type 2, Morbid Obesity, Hypertension, Anxiety Disorder, Insomnia, Unspecified Depressive Episodes, and Polyneuropathy. R3's Minimum Data Set, dated [DATE], documented R3 has no deficits in cognition, is totally dependent on at least two staff for transfers, bed mobility, dressing, eating, and toileting. Nurses Note dated 7/6/23 at 11:54am, authored by V4, Registered Nurse, documented, Resident accused CNA of being rough while completing care. Is cursing and yelling at staff. Attempted to console and allowed resident to vent. Administrator and Director of Nurses…

    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 before2023-08-25 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to immediately initiate and thoroughly investigate allegation of staff to resident abuse for one resident of four residents (R3) reviewed for abuse in the sample of 4. Findings include: R3's Face Sheet documented an admission date of 3/7/23 and diagnoses including Quadriplegia, Tracheostomy, Pressure Ulcer of the Sacrum, Diabetes Type 2, Morbid Obesity, Hypertension, Anxiety Disorder, Insomnia, Unspecified Depressive Episodes, and Polyneuropathy. R3's Minimum Data Set, dated [DATE], documented R3 has no deficits in cognition, is totally dependent on at least two staff for transfers, bed mobility, dressing, eating, and toileting. Nurses Note, dated 7/6/23 at 11:54am, authored by V4, Registered Nurse, documented, Resident accused CNA (Certified Nursing Assistant) of being rough while completing care. Is cursing and yelling at staff. Attempted to console and allowed resident to vent. Administrator and Director of Nurses notified. There was no documentation…

    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
  • No harm found · Bcited before2024-06-28 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review the facility failed to maintain air conditioning equipment and provide comfortable temperatures for 47 of 47 residents (R1-R47) reviewed for environment in a sample of 47. The findings include: On 6/26/2024 at 9:20 AM, while entering the facility through the front door opening into the dining room area, warm temperatures were observed immediately. In the dining room there were 2 PTAC (Packaged Terminal Air Conditioner/ self-contained heating and cooling system) running, and thermostats set at 62 degrees F (Fahrenheit) and 1 portable air conditioner that was vented out the window. There was also a fan running in the dining area. Noted to be 6 residents sitting in the dining room at this time. On 6/26/2024 at 10:10 AM, V6 RN (Registered Nurse) was observed working at the treatment cart of the Southwest (400) Hall. V6 stated the facility has been very warm recently. V6 stated she doesn't understand why the air conditioner servicemen do not make the nursing home a priority. V6 stated the facility has been placing fans and portable air…

    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

“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

$107,564 in federal fines across 3 penalties.

  • $40,476 — penalty dated 2025-08-12
  • $12,284 — penalty dated 2024-02-14
  • $54,804 — penalty dated 2023-08-25

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to HELIA HEALTHCARE — 13 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 52.2-1.2 vs chain
Health inspection 1 of 52.5-1.5 vs chain
Staffing 1 of 51.3-0.3 vs chain
Quality measures 2 of 52.7-0.7 vs chain
The other 12 homes this chain runs (chain average 2.2★, 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
MILLER, STEPHENIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER100%since 03/21/2018
MILLS, MICHAELIndividualCONTRACTED MANAGING EMPLOYEEsince 03/21/2018

CMS files one row per role, so the 3 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

$6.4M
Net patient revenuemost recent cost report
-2.4%
Operating marginrevenue minus expenses
$332K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 76%Medicare 14%Other / private 10%

About 76% 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 $332K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$307per resident / day
operating cost
$9,334per month
≈ monthly operating cost
$300per 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 145247. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-13, 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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