Twin Willows Nursing Center
1600 North Broadway, Salem, IL 62881 · For profit - Corporation · 72 certified beds · (618) 548-0542 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing score sits well above its independent inspection score
- its facility-reported quality-measure rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 1 of 5 |
| Long-stay residentspeople who live here | 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 fell from 5 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 24.3% | 13.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 0.0% | 6.3% | 5.4% | check this* — see note marked star below the table |
| Long-stay residents with a catheter left in their bladder | 5.2% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 9.3% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 10.1% | 54.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.0% | 3.1% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 36.3% | 14.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 25.0% | 18.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 92.9% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.6% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 11.7% | 20.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.1% | 21.7% | 17.1% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.11 | 2.02 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.47 | 2.22 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
Therapy staffing: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.1%CMS range 6.5–15.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The data for this measure is missing or was not submitted. 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 discharge | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.99 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 72 beds and averages 22.2 residents a day — about 31% occupied, or roughly 50 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 4.12 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.61 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.72 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.88 hrs/resident/day on weekends vs 4.22 on weekdays — 8% thinner on weekends. RN hours go from 0.67 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 34% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.
- Potential for harm · F2026-04-03 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
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 the consulting services of a Registered Dietician. This failure has the potential to affect all 22 residents that reside at the facility.Findings include:On 04/01/26 at 2:54 PM, V19 (previous Registered Dietician) stated, she is not familiar with any of the residents at the facility. V19 stated, she has not physically been at the facility since October 2023.On 04/01/26 at 3:10 PM, V8 (Dietary Manager) stated they currently do not have a RD (Registered Dietician), they have not had one since the end of 2023. V8 stated she does not do BMIs (Body Mass Index), goal weights, the amount of calories needed, or estimated calories given for the residents. On 04/01/26 at 3:17 PM, V2 (Director of Nursing) stated they do not currently have a RD, they have not had one for a little while. V2 stated, V19 was their last RD, and it could have been around October 2023 since she has been the facility's RD. The facility document titled, Facility Assessment Tool dated 02/10/26 documents: Part 3: Facility Resources Needed to Provide…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2026-04-03 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 maintain a safe, clean, sanitary environment in the common foyer area of the facility. This failure has the potential to affect all 22 residents residing at the facility.Findings include:On 03/30/26 at 8:50 AM the ceiling vent in the entrance foyer had a large accumulation of a black substance covering approximately 90 % of the vent with a concentration around the edges and the center of the vent.On 03/31/26 at 8:45 AM the ceiling vent in the entrance foyer had a large accumulation of a black substance covering approximately 90 % of the vent with a concentration around the edges and the center of the vent.On 04/01/26 at 8:30 AM the ceiling vent in the entrance foyer had a large accumulation of a black substance covering approximately 90 % of the vent with a concentration around the edges and the center of the vent.On 04/02/26 at 3:10 PM V2 (Director of Nursing) stated, the vents in the foyer area should be cleaned, she will get V20 (Maintenance Director) to clean it right away.The undated facility policy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-04-03 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, observation and record review the facility failed to provide an accessible call light for the shower room on the north hall for 10 (R5, R7, R8, R9, R10, R12, R15, R18, R20, and R22) of 10 residents reviewed for assessable call lights in a sample of 22.Findings include:1.On 03/30/26 at 1:55 PM the shower room on the north hall had a call light but the call light did not have a string to activate it. On 04/02/26 at 9:55 AM the shower room on the north hall had a call light but the call light did not have a string to activate it. On 04/01/26 at 1:19 PM, V12 (Certified Nurse Aide) stated there are shower rooms on the north and the east halls. V12 stated, typically the residents on the north hall would be showered in the shower on the north hall. On 04/02/26 at 3:12 PM, V2 (Director of Nursing) stated the call light in the shower room works the string just broke off. V2 stated, she will have it fixed before she leaves for the day.On 3/30/26 the facility provided a list titled, Wing Group Assignments that documented: R5, R7, R8, R9, R10, R12, R15, R18, R20, and R22…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-04-03 · tag F0805 — failed to prepare food in a form residents can eat — patternEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review the facility failed to serve food in the appropriate texture for 4 (R7, R8, R15, and R22) of 10 residents reviewed for dining in a sample of 22.Findings include:The facility document titled, Patient Literal Orders by Category documents R7, R8, R15, and R22 receive a mechanical soft diet. On 03/31/26 between 11:30 AM and 12:05 PM R7, R8, R15, and R22 received a half a baked potato with the skin still on for their lunch meal. On 03/31/26 at 11:58 AM, R8 was sitting up in her bed in her room. R8 had half a baked potato and a piece of meatloaf on her food tray sitting in front of her. R8 was attempting break off pieces of the baked potato with her fork with her left hand. R8 was able to get a chunk of her baked broke off that was over 1.5 inches in length and put it into her mouth and attempted to chew. R8 then pulled pieces of the potato skin out of her mouth and placed them on the side of her tray. R8 struggled to chew the size of the piece of potato in her mouth.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-04-03 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain adequate infection control practices including hand hygiene, identification of appropriate isolation, and proper handling of soiled linens for 6 of 6 residents (R2, R5, R7, R9, R18, and R20) reviewed to infection control in the sample of 22.Findings include:1. On 3/30/26 at 10:00 AM there were no signs on R20's door indicating she was on any type of isolation.R20's laboratory results dated [DATE], regarding her urine culture, documents she has a urinary tract infection with the causative bacteria identified as Escherichia coli (E.coli),extended-spectrum beta-lactamase (ESBL), and Proteus mirabilis.R20's Physician Order dated 3/16/2026 documents, Augmentin 875/125 milligram (mg) 1 tab by mouth twice daily for 10 days related to E Coli, ESBL, Proteus miabilis per vagina and urine.On 4/1/2026 at 1:55 PM, V4 (Certified Nursing Assistant/CNA) reported R20 has not been on contact isolation recently. V4 stated she had asked V2, Director…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-03 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review the facility failed to provide eating assistance with respect and dignity for 2 (R12, R18) of 3 residents reviewed for dignity in a sample of 22. Findings include:1.R18's admission record documents an admission date of 06/10/21 with diagnoses including: dementia, anemia, major depressive disorder, cataract, gastro-esophageal reflux disease, and age related osteoporosis. R18's Minimum Data Set (MDS) dated [DATE] documents no brief interview of mental status (BIMS) should be conducted due to resident is rarely/never understood. Section GG documents R18's eating performance is dependent, indicating helper does all the effort. On 3/30/2026 at 12:13 PM, V5 Certified Nurses Assistant (CNA) answered her personal cellphone during the lunch meal while she continued to provide bites of food to R18 while talking on her phone. At end of her phone conversation V5 was heard stating, I have to get off here, I'm feeding. The conversation lasted 2 minutes. On 3/30/2026 at 12:43…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-03 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 Uniform Practitioner Orders For Life-Sustaining Treatment (POLST) status reflected resident wishes as desired throughout resident health record for 1 of 2 residents (R19) reviewed for advanced directives in a sample of 22.Findings include:R19's admission Record documented R19 was admitted to this facility on [DATE]. R19's Physician's Order Sheet dated [DATE] documented admitting diagnoses of congestive heart failure, and chronic kidney disease stage 4 among others.R19's MDS (minimum data set) dated [DATE] documented a BIMS (brief interview for mental status) score of 15 out of 15 total, which indicates R19 is cognitively intact.R19's Physician Order Sheet dated [DATE]-[DATE] documented R19 as DNR (do not resuscitate). R19's Physician Order Sheet dated [DATE]-[DATE] documented R19 as DNR. R19's Physician Order Sheet dated [DATE]-[DATE] documented R19 as DNR.R19's Social Service assessment dated [DATE] documents under section titled Advanced…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-03 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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 — the official record, unedited, may be distressing
Based on observation, interview, and record review the facility failed to provide a safe, clean, sanitary environment for one (R2) of ten residents reviewed for a safe, clean, sanitary environment in a sample of 22. Findings include:On 03/30/26 at 10:20 AM the bathroom on the east hall had 10 1 inch by 1 inch tiles missing in the floor near the toilet and 20 1 inch by 1 inch tiles missing in another location on the floor. There was also a build up of dirt and debris around pedestal of the toilet. On 04/02/26 at 3:10 PM, V2 (Director of Nursing) stated, R2 is the only resident that uses the bathroom on the east hall. V2 stated she will get V20 (Maintenance Director) to clean and repair it right away.The undated facility policy titled, Facility Environmental Policy documents: it is the policy of (facility name) to provide housekeeping and maintenance staffing to promote a safe and functional environment.
- Potential for harm · D2026-04-03 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review the facility failed to accurately assess a resident eating abilities for 1 of 1 resident (R2) reviewed for accuracy of assessments in a sample of 22.Findings include:R2's admission record documents an admission date of 02/18/26 with diagnoses including: neurocognitive disorder with Lewy Bodies, anxiety disorder, progressive spinal muscle atrophy, and insomnia. R2's Minimum Data Set (MDS) dated [DATE] documents a brief interview of mental status (BIMS) of 01 indicating severe cognitive impairment. Section GG documents R2's eating performance as independent.R2's care plan for 3/9/26 documents a focus area of: potential for excessive weight gain or loss related to Lewy body dementia, progressive atrophy, confusion and hand tremors. Interventions to include: R2 can feed himself, he often requests seconds of foods he likes, attempt to second helping when he requests, monitor meal intake with every meal.R2's Malnutrition Risk assessment dated [DATE] documents in part…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-03 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review the facility failed to provide assistance with eating assistance in a timely manner and failed to ensure that residents who require assistance with showering received a shower for 2 of 4 residents (R2, R7) reviewed for Activities of Daily Living in a sample of 22.Findings include:1. R2's admission record documents an admission date of 02/18/26 with diagnoses including: neurocognitive disorder with Lewy Bodies, anxiety disorder, progressive spinal muscle atrophy, and insomnia. R2's Minimum Data Set (MDS) dated [DATE] documents a brief interview of mental status (BIMS) of 01 indicating severe cognitive impairment. Section GG documents R2's eating performance as independent. This same MDS documents R2 needs partial/moderate assistance from one staff member for showering R2's care plan for 3/9/26 documents a focus area of: potential for excessive weight gain or loss related to Lewy body dementia, progressive atrophy, confusion and hand tremors. Interventions to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 17 citations
- Potential for harm · Dcited before2026-04-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to supervise residents who are at risk of choking during meals for 1 of 1 resident (R23) reviewed for supervision in the sample of 22. Findings include:R23's admission Records documents R23 was admitted on [DATE] with diagnoses to include: muscle wasting and atrophy, gastro-esophageal reflux disease, muscle weakness, need for assistance with personal care.R23's Minimum Data Set (MDS) dated [DATE] documents R23 is severely cognitively impaired and she requires partial to moderate assist with eating.R23's care plan dated 1/14/2026 documents, Potential for nutritional problem related to: she is unsatisfied with the idea of gaining weight, Lasix therapy, and choking hazard. The interventions for this care plan include, Staff supervision with all meals related to choking hazard. Monitor for any signs or symptoms of aspiration, or dysphagia: choking, fever coughing.On 3/30/26 from 12:54 PM to 1:11 PM R23 was observed feeding herself chicken strips,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-03 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review the facility failed to assess, monitor and document meal intakes on resident who is considered underweight for weight gain/loss for 1 of 5 residents (R9) reviewed for weight loss in a sample of 22.Findings include:R9's admission record documents an admission date of 02/12/15 with diagnoses including: Alzheimer's disease, dementia, methicillin resistant staphylococcus aureus infection, essential hypertension, extended spectrum beta lactamase resistance, major depressive disorder, gastro-esophageal reflux disease (GERD), and hypothyroidism.R9's Minimum Data Set, dated [DATE] documents the question; should brief interview for mental status with no marked indicating resident is rarely/never understood. Section GG documents eating status of dependent indicating helper does all of the effort. Section K documents a height of 65 inches and a weight of 102 pounds.R9's care plan last revised 3/3/26 documents a problem area indicating R9 has the potential for excessive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-01-16 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, observation and record review the facility failed prevent cross contamination of drinking glasses during meal service. This failure has the potential to affect all 24 residents residing at the facility. Findings include: On 01/13/24 at 11:43 AM, V4 (Certified Nurse Aide/CNA) delivered drinks to the residents in the dining room by the rim of the glass, where the residents drink from, after touching the kitchen door, the drink cart handle, her jeans, and the handles of several wheelchairs without any hand hygiene performed. On 01/13/24 at 11:40 AM, V4 delivered the drink cart to the hall with the drinks in a tote with ice in the bottom and no lids or covering over the drinks. On 01/14/24 at 11:47 AM, V4 delivered drinks to the residents in the dining room by the rim of the glass, where the residents drink from, after touching the drink cart handle, her jeans, and the handles of several wheelchairs without any hand hygiene performed. On 01/14/24 at 11:45 AM, V11 (CNA) was serving uncovered drinks from the hall cart, by the rim after touching the handle of the drink…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-01-16 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 a safe, sanitary, and clean home-like environment for the residents. This has the potential to affect all 24 residents residing at the facility. Findings including: On 01/13/24 at 12:53 PM, the shower room on the 200 hall had an accumulation of dirt and mildew along the edges between the floor and the wall in the caulk of all three walls of the shower stall. In this same room there is was accumulation of dirt on the floor in between the 1 inch by 1 inch tiles. There is an accumulation of dirt and debris along the edge of the bottom of the toilet where the toilet meets the floor. There was an approximate 2 millimeter black ring inside the toilet bowl. There was a large linen barrel and trash can blocking access to the hand washing sink. On 01/13/24 at 12:57 PM, in shower room on the 400 hall there was an accumulation of a black substance between the floor and wall on the left side of the shower stall and at the ridge between the shower stall and the bathroom floor. There are three 4 inch by 4 inch tiles…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-01-16 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure call lights were within reach for 6 of 7 residents (R1, R5, R11, R19, R21, R24) reviewed for call lights on the sample list of 23. Finding include: 1. R19's admission Record documents diagnoses including in part dementia and an admission date of 9/8/23. R19's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) of 7, indicating R19 has severe cognitive impairment. R19's MDS dated [DATE] documents R21 has had falls with injury, including skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains or any fall related injury that causes the resident to complain of pain since admission/entry or reentry or the prior assessment. R19's Care Plan with review date of 12/27/24 documents a problem area of potential for injury related to falls related to decreased strength. Activities of daily living function decline, cognitive loss, history of falls, intermittent vertigo. R19 does ambulate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-16 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review the facility failed to promote dignity for 1 of 4 (R17) reviewed for dignity in a sample of 23. Findings included: 1. R17's admission Record dated 3/8/2022 documents an admission date of 03/08/22 with diagnoses in part of unspecified dementia, dysphagia oral phase, and weakness. R17's Minimum Data Set (MDS) dated [DATE] documents in Section C a Brief Interview for Mental Status (BIMS) that interview could not be completed due to R17 is rarely or never understood. Staff interview for mental status documents short- and long-term memory problems. This indicates R17 has severally impaired cognition. Section GG documents under eating that R17 requires substantial to maximal assistance with eating. R17' Care Plan dated 12/20/24 documents under problem: Potential for significant weight loss r/t (related to) GERD (Gastroesophageal Reflux), peptic ulcer, poor appetite, weakness, slow eater, dyspnea. R17 is resistant at times to allow staff assist with meals. R17 tends to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-16 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed investigate a bruise of unknown origin for 1 (R13) of 1 resident reviewed for bruises of unknown origin in a sample of 23. Findings include: R13's admission Record documents an admission date of 09/12/22 with a diagnosis including: progressive supranuclear ophthalmoplegia (Steele-[NAME]-[NAME]). R13's Minimum Data Set, dated [DATE] documents a brief interview of mental status (BIMS) score of 2 indicating severely cognitively impaired. R13's nurse's note dated 11/10/24 at 10:00 AM documents: dark purple bruise observed on Rt (right) buttocks (5.5 cm (centimeters) - length, 4.5 cm - width) No open areas. Bruise of unknown origin. Resident denies having any pain or discomfort. Resident does not know how bruise was obtained. POA (power of attorney) aware and the doctor notified with no new orders. No edema to the bruise. On 01/15/24 at 1:22 PM, R13 stated she does not remember what happened when she had the bruise on her bottom. On 01/16/24 at 1:05 PM, V2…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-16 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review the facility failed to provide necessary services that are consistent with professional standards to prevent the worsening of pressure ulcers for 1 of 2 residents (R4) reviewed for pressure ulcers in a sample of 23. Findings include: R4's admission record dated 03/01/2022 has an admission date of 07/10/20 with diagnoses in part of Type 2 diabetes mellitus, morbid obesity, venous insufficiency, muscle weakness and need for assistance with personal care. R4's Minimum Data Set (MDS) dated [DATE] documents in Section C a Brief Interview for Mental Status (BIMS) score of 15 which indicates that R4 is cognitively intact. Section M documents this resident at risk of developing pressure ulcers/injuries answers as yes. Does this resident have one or more unhealed pressure ulcers/injuries answers as no. R4's Care Plan last revised 11/18/24 documents in part a problem of R4 currently has excoriation and darkened areas on his buttocks. R4 is totally incontinent of bowel and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to implement active, cognition appropriate and progressive interventions to prevent falls for three (R5, R19, R21) of six residents reviewed for falls in a sample of 23. Findings include: 1. R5's admission Record documents diagnoses including in part dementia. admission Record documents R5 was admitted on [DATE]. R5's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 9, indicating R5 has moderate cognitive impairment. MDS dated [DATE] documents R5 is independent with transfers, has no impairment in the upper or lower extremities and uses a walker for mobility and usually understands others during conversation. R5's MDS documents R5 has had falls with injury, including skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains or any fall related injury that causes the resident to complain of pain since admission/entry or reentry or the prior assessment. R5's Care Plan with a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-16 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review the facility failed to follow the facility policy for weight loss for one (R24) resident of 3 residents in a sample of 23. Findings include: R24's admission Record documents an admission date of 07/22/24 with diagnoses including: Parkinsonism, anemia, Alzheimer's disease, and cerebral infarction. R24's Current Care Plan documents: problem: Potential for excessive weight loss r/t (relating to) forgetting to eat r/t Parkinson's, dementia, Alzheimer's/cognitive loss. R24 tends to be a very pick eater. The intervention section documents: undated interventions of: R24 is on regular diet, likes and dislikes assessment, R24 reports that her favorite foods include meatloaf, potatoes of all kinds, hamburgers, banana pudding, ice cream, she reports that she does not like mixed vegetables, broccoli, spinach or many vegetables of any kind, follow likes/dislikes assessment and honor her other verbal dislikes for food, R24 can feed herself. She does not request alternate foods…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-16 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a resident with dementia received the necessary person-centered care and services to address wandering behavior for 1 of 1 resident (R14) reviewed for Dementia in the sample of 23. Findings include: R14's admission Record documents an admission date of 03/16/21 with diagnoses including: dementia without behavioral disturbance and altered mental status. R14's Minimum Data Set, dated [DATE] documents no brief interview of mental status was performed due to resident is rarely or never understood. R14's Current Care Plan does not include any problem area for wandering into other residents rooms. 1. On 01/13/24 at 1:21 PM, R24 was heard yelling help two times at 1:24 PM when surveyor looked in R24's room to check on R24, V6 (Certified Nurse Aide) came out of a different resident's room and looked down the hall and saw surveyor and asked, did I hear someone yell help ? Surveyor replied, yes and V6 came down and checked on R24. R14 was in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-16 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow proper infection control technique during incontinent care for 1 of 2 (R4) residents observed for incontinent care in a sample of 23. Findings included: R4's admission record dated 03/01/2022 has an admission date of 07/10/20 with diagnoses in part of Type 2 diabetes mellitus, morbid obesity, venous insufficiency, muscle weakness and need for assistance with personal care. R4's Minimum Data Set (MDS) dated [DATE] documents in Section C a Brief Interview for Mental Status (BIMS) score of 15 which indicates that R4 is cognitively intact. Section GG documents toileting as dependent and personal hygiene as substantial/maximal assistance. R4's Care Plan dated 11/18/24 documents in part a problem of R4 currently has excoriation and darkened areas on his buttocks. R4 is totally incontinent of bowel and bladder. R4 is resistive to lying on his side as a preventative. Interventions include in part when incontinent, wash, rinse and dry…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-16 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
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 follow standards of practice for antibiotic use for one (R3) of one resident reviewed for antibiotic use in a sample of 23. Findings include: R3's admission Record documents an admission date of 10/29/24 with diagnoses including: anxiety disorder, cerebral infarction, chronic kidney disease, gastro esophageal reflux disease without esophagitis, and adult failure to thrive. R3's Physician's Order sheet documents an order dated 01/08/25 for: z-pak r/t (relating to) bronchitis. The facility document dated Jan (January) 2025 titled, Infection Control Log (new form) documents: resident (R3), onset date: 01/08/25, date resolved: 01/13/25, infection related dx (diagnosis) respiratory, culture: the no column is checked, organism: with nothing listed, antibiotic: z-pack, isolated: with the column no checked, nosocomial: with the column yes checked. R3's nurse's notes dated: 12/23/24 (R3) has zero sign or symptoms of distress, zero signs or symptoms of covid, zero cough or congestion, zero nasal drainage, zero…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-07-08 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation interview and record review the facility failed to store food in accordance with professional standards for food service safety. This failure has the potential to affect all 29 residents currently residing at the facility. Findings Include: The facility Wing Group Assignments provided to this surveyor on 7/6/24 documents 29 residents currently reside at the facility. On 7/6/24 at 9:26 AM, V2 (Director of Nurses) stated the facility freezer went down and they moved all of the food off premises to a dedicated freezer in a secure place at V2's house. V2 stated they maintain the temperature of the freezer. V2 was unable to provide this surveyor with reproducible evidence the temperature of the freezer/food was maintained per current standards of practice. On 7/6/24 at 10:06 AM, V4 (Cook) stated they don't have a working freezer at the facility. V4 stated the unit went down about two weeks ago. V5(Dietary Aid/Cook) stated V2 is taking the food to her house to store in a freezer and she brings the food they need to the facility each day. V4 stated they check the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-05 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
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 assessments were successfully transmitted within 14 days of completion for 1 (R9) of 12 residents reviewed for assessments in the sample of 22. Findings Include: R9's admission Record documented an initial admission date to the facility as 12/20/2018. Diagnoses included, but were not limited to: unspecified dementia, dysphagia, type 2 diabetes mellitus, seizures, macular degeneration, etc. Review of R5's Minimum Data Set, dated (MDS) 7/29/23, documented the type of assessment as being a reporting entry for death in facility. This same assessment documented the discharge date for R9 in section A2000 as 07/29/2023. On 01/03/24 at 02:40 PM, V5 (Medical Records) stated the death in facility MDS was completed on for R9 on 7/29/23. In reviewing the electronic record, V5 stated the MDS although complete, was inadvertently not submitted. V5 stated she will get the document submitted today. Review of CMS (Centers for Medicare & Medicaid Services) MDS NH (Nursing Home) Final Validation Report documented completed submission…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-05 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to offer/provide showers for 2 of 12 (R136 and R137) residents reviewed for showers in a sample of 22. The Findings Include: 1. R137's admission record documents an admission date of 12/28/23 with diagnoses including heart failure and unspecified osteoarthritis. R137 does not yet have a completed Minimum Data Set, but R137 was alert to person, place, and time during the interview on 1/3/24 at 10:00 AM. R137's baseline care plan dated 12/28/23 documents she is dependent for showers. On 1/3/24 at 10:00 AM, R137 stated she has not had a shower since admission, and they changed her out of her pajamas at 4AM and put her clothes on from the previous day. R137 stated at this time she would like to have clean clothes on daily and to not get too close because she likely smells. R137 stated she has not asked for a shower, but assumes it is in the plan soon. On 1/3/24 at 2:41 PM, R137 stated she has never received a bed bath. R137 stated she recalls receiving a washcloth one time and that is what she used to wash her hands since…
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.
- No harm found · C2025-01-16 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review and observation the facility failed to post daily nurse staffing data for licensed and unlicensed staff responsible for resident care. This failure has the potential to affect all 24 residents who reside at this facility. Findings included: On 1/13/2024 at 12:00pm, the facility's daily staff posting was noted on the wall across from the south hall nurses station. The date on the staff posting is noted to be 2/26/24 and documented a census of 32 residents. On 1/14/2025 at 12:00pm, the facility's daily staff posting was noted on the wall across from the south hall nurse's station. The date on the staff posting is noted to be 1/14/25 and documented a census of 24 residents. On 1/15/2025 at 1:00pm, the facility's daily staff posting was noted on the wall across from the south hall nurse's station. The date on the staff posting is noted to be 1/14/25. On 1/15/2025 at 1:00pm, V3 agreed the facility's daily staff posting was not current, but should be and probably just was missed today. On 1/16/2025 at 12:05pm, the facility's daily staff posting was noted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| WOODRUFF, HELEN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 95% | since 02/14/1976 |
| WOODRUFF, JEFFREY | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; ADP OF THE SNF | 5% | since 02/14/1976 |
| WOODRUFF, TODD | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2018 |
CMS files one row per role, so the 10 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.
What families pay in IL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 146070. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-03, 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 →
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