Pavilion On Main Street, The

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

40.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 83 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 40.7% 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 54 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 0.32 therapist hours per resident per day in 2026Q1 — more than 52% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 50% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 113 beds and averages 91.6 residents a day — about 81% occupied, or roughly 21 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.98 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.72 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.82 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.71 hrs/resident/day on weekends vs 3.09 on weekdays — 12% thinner on weekends. RN hours go from 0.77 to 0.60 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 35% 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

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

29 citations, most serious first. The 14 most serious are shown; the remaining 15 are one tap away and print in full.

• Actual harm · Gcited before2025-09-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a bed rail was maintained in a safe manner for 1 of 3 residents (R1) reviewed for resident injury in the sample of 9. This failure resulted in R1 receiving an injury to her right lateral leg, being sent to a local hospital where she received stitches for her injury.The findings include:R1's admission Record, printed by the facility on 9/16/2025, showed she had diagnoses including, but not limited to, displaced comminuted fracture of shaft of humerus left arm (5/6/25), moderate protein-calorie malnutrition, difficulty in walking, reduced mobility, lack of coordination, pain in left should and left elbow, disorders of muscle, dysphagia, unsteadiness on feet, need for assist with personal care, age-related osteoporosis , repeated falls, hypertension, muscle spasm, history of healed stress fracture, dementia, glaucoma, weakness, abnormal gait and mobility, and malignant neoplasm of skin. R1's facility assessment dated [DATE] showed she…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-08-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review the facility failed to safely handle a resident to prevent multiple skin tears. This failure resulted in R92 being transferred to the emergency room (ER) after a transfer which contributed to R92 sustaining a large skin tear requiring 11 stitches/sutures. This applies to 1 of 23 residents (R92) reviewed for safety in the sample of 23. Findings include:R92's progress notes dated 8/23/25 shows, Resident noted with a skin injury to the left lower leg. The incident occurred during transfer from the wheelchair to the bed, the CNA (certified nursing assistant) reported. MD (V21 R92's medical doctor (MD)) is informed with order to transfer resident to ER. R92's skin tear report dated 8/23/25 shows, Informed by the CNA (V20) that while providing care noted blood stain on sock and when sock was removed noted wound to left lower leg. Blood was new.R92's progress note dated 8/24/25 shows, Resident returned from ER at approximately 00:15 (12:15 AM) with daughter (V19) and EMS (emergency medical system). Resident received 11 sutures (stitches) to…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-08-27 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review the facility failed to ensure dietary recommendations were implemented for residents with a history of significant weight loss. This failure resulted in R43 and R93 not receiving their therapeutic diets as ordered for their severe weight loss. This applies to 2 of 9 residents (R43, R93) reviewed for weight loss in the sample of 23. Findings include:On 8/25/25 at 10:32 AM, V5 Dietary Manager added 21 cooked, individual chicken nuggets into the facility's food processor. V5 stated, she was making puree for 11 residents. V5 stated, regular diets will get 5 chicken nuggets per person. (There should have been 55 nuggets pureed for 11 pureed diets but only pureed half of the amount she should have). The spreadsheet for the noon meal on 8/25/25 shows, regular diets should get 5 chicken nuggets to equal 2 ounces of protein per person. 1. R43's face sheet lists his diagnoses to include: toxic encephalopathy, dysphagia and dementia. R43's meal ticket shows, pureed diet with double portions on every tray. On 8/25/25 at 11:51 AM, R43 was eating…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-09-28 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide pain control for a resident with fractured ribs for 1 of 1 resident (R289) reviewed for pain. This failure resulted in R289 experiencing difficulty sleeping, difficulty participating in therapy and uncontrolled pain. The findings include: R289's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include multiple fractures of ribs, left side, need for assistance with personal care, abnormalities of gait and mobility, opioid dependence, spinal stenosis, low back pain, and intervertebral disc degeneration lumbar and lumbosacral region. R289's 9/20/23 Clinical admission note entered at 7:19 PM showed R289 reported an aching and radiating pain to left lower back at a 4 on the pain scale with the frequency of the pain being constant. R289's care plan initiated 9/21/23 showed, [R289] has acute/chronic pain related to disease process and multiple left rib fractures . [R289] will verbalize adequate relief of pain…

  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 before2025-10-09 · 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 ensure resident safety during transportation to an outside appointment for 1 of 3 residents (R1) reviewed for safety in the sample of 4. The findings include:R1's face sheet printed on 10/9/25 showed diagnoses including but not limited to compression fracture of fifth vertebra (at admission), rheumatoid arthritis, spondylosis of the cervical region and lumbar region, and spinal stenosis. R1's facility assessment dated [DATE] showed no cognitive impairment and total staff assisted needed for transfers. The same assessment showed R1 needed staff supervision or touch assistance with wheelchair use. R1's progress note dated 5/19/25 at 1:30 PM, stated the resident returned to the facility following an orthopedic appointment. Nurse on duty was notified that resident fell from her wheelchair outside of the physician's office. A full assessment was done, and a hematoma (collection of blood trapped under the skin/bruise) was observed on the right side of her…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-09-18 · 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 a resident's medications were available and administered as ordered for 1 of 3 residents (R4) reviewed for medications in the sample of 10.The findings include: On 9/17/2025 at 8:39 AM, V6 (R4's wife) said R4 did not get his medications for 3 days when he was first admitted to the facility. V6 said she was not sure what medications. V6 said R4 just told her he was not getting all his medications. V6 said the facility told them the hospital did not send them. V6 said, I could not go into the facility when he was first admitted because I had the flu. I told (R4) to say something about not getting all his medications. V6 said she knows she spoke to someone about the medications. V6 said, He is on a lot of medications. I was worried he was going to have withdrawal because he is on methadone. V6 could not identify who she spoke to at the facility regarding R4's medications. V6 said when R4 was discharged from the facility back to home, they did not…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-08-27 · tag F0803 — failed to meet residents' dietary needs — widespread
  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 prepare pureed foods in a manner to maintain its nutritive value. The facility failed to serve mechanical soft foods to residents that required a mechanical soft diet. The facility failed to serve foods according to their daily menu.These failures apply to all 97 residents in the facility. Findings include:1. A facility list dated 8/25/25 showed 11 residents required a pureed diet.Chicken nuggets, cooked carrots, potatoes, bread, and melon were the food items listed on the facility's lunch menu/spreadsheet dated 8/25/25. The menu/spreadsheet showed each resident was to receive a total of 5 chicken nuggets, for a total of 2 ounces of protein, at lunch. The facility's pureed chicken nugget recipe printed 8/25/25 showed each resident on a pureed diet was to be served the pureed equivalent of 5 chicken nuggets for lunch. The recipe showed facility kitchen staff were to add 3 tablespoons of chicken broth to each 2 ounce portion of chicken nuggets to make the puree. Staff were to add thickener as needed to make the…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-08-27 · 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 ensure kitchen utensils were stored in a sanitary manner. The facility failed to ensure food was prepared in a manner to prevent cross contamination. The facility failed to ensure kitchen staff covered facial hair to prevent cross contamination. The facility failed to maintain the kitchen in a sanitary manner. These failures have the potential to affect all 97 residents in the facility. Findings include:The facility's Long-Term Application for Medicare and Medicaid form date 8/25/25 showed a resident census of 97. On 8/25/25 from 9:11 AM-9:25 AM, the following observations were noted during the initial tour of the facility's basement kitchen: The garbage container located under the handwashing sink was overflowing with garbage. The kitchen floor, by the oven and the food prep table, was sticky. Food and liquid debris were noted on the floor in these areas. Dried liquid and food debris were noted on the sides and front of the oven. A sticky substance was noted to the sides and front of a food processor. Multiple…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-08-27 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review the facility failed to ensure residents receiving pureed diets were served appetizing and flavorful meals for 4 of 4 residents (R73, R43, R93 & R6) reviewed for palatability in the sample of 23. Findings include:On 8/25/25 at 9:13 AM, R73 was in his room eating his morning breakfast tray. R73 said he must have his food pureed and the food here just sucks, and I can't eat most of it. R73's tray was noted to still have a full bowl of hot breakfast cereal, and what he reported to be pureed pancakes. R73 said he was not sure what the other meal item on the tray was, but he was done and could not eat it. R73's morning meal ticket shows he should have pureed pancakes, cream of rice, and pureed scrambled eggs.On 8/25/25 at 12:33 AM, R73 was in his room eating his lunch. R73's meal ticket showed he should have on his meal tray pureed chicken nuggets, carrots, fruit and bread. R73 said the chicken nuggets were terrible and he could not eat them. The chicken nuggets were in a ball on the tray and looked like a big ball of stuffing. On 8/25/25…

  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 · D2025-08-27 · 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 — the official record, unedited, may be distressing

  Based on observation, interview, and record review the facility failed to provide a homelike environment. This applies to 2 of 23 (R8, R85) reviewed for homelike environment in the sample of 23. Findings include:On 8/25/2025 at 9:44AM, R8 and R85 room was observed to have heavy gouging behind both residents' headboards and behind R85's recliner. The area with heavy drywall gouging and missing paint is approximately 2-3 feet by 2-3 feet tall behind the headboards and recliner.On 8/26/2025 at 12:00PM, V16 Director of Maintenance said work orders are put in the [app] by staff or by him when issues are reported to him. V16 said there is not a work order for that room. V16 said resident rooms should have no wall damage or holes.The facility provided Quality of Life - Homelike Environment dated 4/2014 states, . residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-27 · 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

  Based on interview and record review the facility failed to ensure baths were provided as scheduled for 2 of 23 residents (R56 & R91) reviewed for Activities of Daily Living (ADL's) in the sample of 23. Findings include:1. R56's ADL care plan initiated on 1/12/24 shows she has an ADL self-care deficit and requires assistance from staff for bathing/showering.The first-floor shower schedule shows R56 should receive showers on Tuesday morning shift and Friday evening shift. R56's Bath and Shower Report Sheet shows she had showers on 8/8/25 and not again until 8/19/25. R56's Electronic Medical Record (EMR) tasks/shower documentation conflicts with R56's shower sheets and has checkmarks indicating that R56 had both a shower and a bed bath on 8/12/25 (Tuesday). On 8/27/25 at 9:40 AM, R56 said, A couple weeks ago it did happen it was on a Tuesday that I did not get my shower. I was told by staff there was too much going on and they would try to come back and do one, but no one ever did.A Concern/Compliment Form shows V22 (R56's) son filed a grievance on 8/17/25 that R56 did not receive her…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-27 · 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

  Based on observation, interview and record review the facility failed to follow physician's orders for a dermatology consult for a resident with a persistent body rash, ongoing since July 2025. This applies to 1 of 23 residents reviewed for quality of care in a sample of 23. Findings include: On 8/25/2025 at 12:30 PM R64 was in his room sitting in his wheelchair. R64 had a red, scabby rash covering his arms and abdomen. R64 stated it has been going on for a while and the facility recently tried a new cream on him. R64 stated, They used the whole tube. R64 stated he was treated for scabies in July, which he thinks it is, but the rash still continues. R64 stated he continues to be very itchy. R64 stated the rash is also on his inner thighs. R64 stated his son was supposed to be taking him to the dermatologist soon. On 8/26/25, during the Resident Meeting, R64 was observed scratching and picking at scabs on his arms. R64's Physician's Order Sheet shows he was treated with Permethrin Cream on 7/9/25 for the same rash. R64's Progress Notes dated 8/7/25 state, Refer to dermatology 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-27 · tag F0759 — failed to keep medication error rate low — isolated
  Ensure medication error rates are not 5 percent or greater.
  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 administer medication as ordered. There were 30 opportunities with 2 errors resulting in a 6.67% error rate. This applies to 2 of 4 residents (R51, R35) reviewed for medication administration in a sample of 23. Findings include:1. On 8/26/2025 at 8:45AM V15(RN) took a new needle from the medication cart drawer and applied it to the Insulin Degludec (Long-Acting Insulin) pen. V15 then dialed the pen to 20 units and administered the medication to R51. V15 did not prime the needle prior to administration of the insulin. When questioned, V15 stated, We only have to prime the needle with the first dose from the pen. The Manufacturer's Guidelines for the administration of the insulin state, Instructions for use Priming your (Insulin) pen: Turn the dose selector to select 2 units, Hold the pen with the needle pointing up. Tap the top of the pen gently a few times to let any air bubbles rise to the top, Hold the pen with the needle pointing up. Press and hold in the dose button until the dose counter shows 0. The 0 must…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-27 · 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

  Based on observation, interview and record review the facility failed to ensure the glucose monitoring machine was cleaned after each resident use. This applies to 2 of 23 residents (R21 and R23) reviewed for infection control in the sample of 23. Findings include:On 8/26/2025 at 8:30 AM V15 (RN) used the blood glucose monitoring machine to check R21's blood sugar. After getting the result V15 returned to the medication cart, took a new test strip from the bottle and a new lancet from the drawer and without cleaning the machine proceeded to go to R23's room and checked her blood sugar. V15 then returned to the medication cart in the hallway again and put the blood glucose machine into the top drawer of the cart. V15 was asked if/when the facility cleans the blood glucose monitoring machines. V15 stated, We clean the machine after each shift with the purple wipes. R21's Physician's Order Sheet dated 8/26/25 shows R21 has an order for Insulin Aspart (Fast acting insulin) per sliding scale before meals and at bedtime. Within this order there is a place to enter R21's blood sugar…

  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

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

Fines & penalties

$93,883 in federal fines across 2 penalties. 2 Medicare payment denials on record.

• $52,234 — penalty dated 2025-08-27
• $41,649 — penalty dated 2023-09-28
• Medicare payment denial — starting 2025-09-24 for 48 days
• Medicare payment denial — starting 2023-10-25 for 9 days

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

Part of a chain

This home belongs to PAVILION HEALTHCARE — 5 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 →

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

CMS files one row per role, so the 16 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

This home reported $1.5M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

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