Sandwich Living & Rehab Center

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.

Therapy staffing: this home’s payroll records show 0.14 therapist hours per resident per day in 2026Q1 — more than 11% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 34% 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 63 beds and averages 31.0 residents a day — about 49% occupied, or roughly 32 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.34 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.71 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.05 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.07 hrs/resident/day on weekends vs 3.45 on weekdays — 11% thinner on weekends. RN hours go from 0.63 to 0.89 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 56% is well above 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 fewer than at the previous inspection — improving. 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.

57 citations, most serious first. The 23 most serious are shown; the remaining 34 are one tap away and print in full.

• Immediate jeopardy · Kcited before2026-02-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  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 ensure water in resident rooms and a shower room used by residents was at a safe temperature. On 2/2/26 at 10:42 AM the bathroom sink in R3's room had a water temperature measuring 149.5 degrees. The South Shower Room shower water measured 146.5 degrees and the water in R17's bathroom sink measured 145.5 degrees. This has the potential to affect all 13 of 13 residents (R1, R3, R4, R5, R7, R13, R15, R17, R19, R21, R24, R30, R36) residing on the South Hall of the facility reviewed for safety.The Immediate Jeopardy began on 2/2/26 when the water temperatures on the South Hall measured between 145 and 153.5 degrees Fahrenheit. V1 (Administrator) was notified of the Immediate Jeopardy on 2/3/26 at 12:30PM. The surveyor confirmed by observation and interview that the Immediate Jeopardy was removed on 2/2/26 but noncompliance remains at Level Two because additional time is needed to evaluate the effectiveness of changing the settings on the hot water heater, scheduling repairs on the hot water heater to prevent…

  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
• Immediate jeopardy · J2024-07-03 · tag F0805 — failed to prepare food in a form residents can eat — isolated
  Ensure 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 observation, interview, and record review the facility failed to provide an altered diet for a resident with dysphagia for 1 of 3 residents (R6) reviewed for therapeutic diets in the sample of 22. This failure resulted in R6 experiencing a choking episode requiring the Heimlich Maneuver and abdominal thrusts to dislodge. The Immediate Jeopardy began on 4/26/24 when an order was received to downgrade R6's diet from regular consistency to a mechanical soft consistency and R6 continued to be served a regular diet. V18 (Registered Nurse) was notified of the Immediate Jeopardy on 6/28/24 at 11:10 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 6/28/24 at 3:47 PM, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R6's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include sepsis, Type 2…

  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
• Immediate jeopardy · Jcited before2023-12-08 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility neglected to ensure a resident (R1) was assessed and provided pain management in a timely manner after being dropped from a mechanical lift on 11/21/23 at 5:30 AM which resulted in a right hip fracture. The facility neglected to notify the physician in a timely manner and provide ongoing nursing assessments, pain assessments, and pain management from the time of the incident on 11/21/23 at 5:30 AM through 11/22/23 at 1:25 AM (approximately 20 hours) when R1 was transported to the emergency department for evaluation and treatment of a right hip fracture. These failures resulted R1 being placed on bedrest without necessary care and effective pain management services being provided. R1 required medical evaluation and treatment at the hospital on [DATE] due to a right hip fracture sustained in a fall during a mechanical lift transfer at the facility. This applies to one of three residents (R1) reviewed for neglect in the sample of five. This failure resulted in an…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-12-08 · 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 I. Based on interview and record review the facility failed to ensure a resident (R1) was safely transferred with a mechanical lift device. This failure resulted in R1 sustaining a hip fracture on 11/21/23 at 5:30 AM during a mechanical lift transfer after the lift device tipped over with R1 in the sling on the device. R1 required medical evaluation and treatment at the hospital on [DATE] due to a right hip fracture that was sustained when the mechanical lift tipped over. This applies to one of three residents (R1) reviewed for safety in the sample of five. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 11/21/23 at 5:30 AM when facility staff dropped R1 in a mechanical lift resulting in a fracture to her right hip. The facility was notified of the Immediate Jeopardy on 12/7/23 at 11:23 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 12/08/23; however, noncompliance remains at a Level Two because additional time is…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-12-05 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to identify a wound prior to becoming a deep tissue injury (DTI), failed to ensure pressure ulcer interventions were in place, and failed to ensure weekly wound assessments were done for 2 of 5 residents (R11, R19) reviewed for pressure ulcers in the sample of 13. These failures resulted in R11 being at an increased risk of infection and delayed wound healing. The findings include: 1. R11's face sheet printed on 12/4/24 showed an admission date of 7/13/24 and diagnoses including but not limited to fracture of right lower leg, urinary tract infection, pneumonia, and peripheral vascular disease. R11's facility assessment dated [DATE] showed no cognitive impairment and staff assistance required for transfers and toileting hygiene. The same assessment showed R11 is always incontinent of urine and bowel. R11's pressure ulcer risk assessment dated [DATE] showed a moderate risk for pressure ulcer development. R11's December 2024 physician orders…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-12-05 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to prevent an unplanned, significant weight loss for 1 of 2 residents (R8) reviewed for nutrition in the sample of 13. This failure resulted in R8 sustaining a 7.98% weight loss over 1 month. The findings include: R8's face sheet printed on 12/4/24 showed diagnoses including but not limited to cerebral infarction, Parkinson's disease, depression, vomiting without nausea, and dysphagia (difficulty swallowing). R8's facility assessment dated [DATE] showed no cognitive impairment and partial to moderate staff assistance for eating. The same assessment showed full staff dependence for transfers. On 12/3/24 at 12:23 PM, R8 was seated at the lunch table with a pureed texture meal in front of her. A magic cup nutritional supplement was next to her plate and R8 was using a sippy-type cup. R8's head was down, and she was not eating. R8 appeared thin and fragile. R8 was missing multiple teeth. Several staff members approached R8 throughout the meal but…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-09-24 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident was free of physical abuse for 1 of 3 residents (R1) reviewed for abuse in the sample of 7. This failure resulted in R1 being punched in the face by R2. The findings include: R1's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include Type 2 Diabetes, repeated falls, essential hypertension, generalized anxiety disorder, chronic obstructive pulmonary disease, psychoactive substance abuse, muscle spasm, hypokalemia, unsteadiness on feet, and abnormalities of gait and mobility. R1's facility assessment dated [DATE] showed he has no cognitive deficits and verbal behavioral symptoms directed toward others. R1's care plan initiated 4/22/24 showed, Resident is known to display/has history of paranoid thoughts/behaviors and or open conflict/criticism with others including false accusations. Specific behavior exhibited: verbal aggression towards staff, false accusations, inappropriate gestures 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-01-25 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement interventions for a resident experiencing significant weight loss for 1 of 4 residents (R8) reviewed for weight loss in the sample of 17. This failure resulted in R8 experiencing a 19.47% weight loss from 11/23/23 to 1/24/24 (2 months and 1day.) The findings include: R8's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include abnormal posture, cerebral infarction, dysphagia, Gastro-Esophageal Reflux Disease, major depressive disorder, Type 2 Diabetes, and weakness. R8's facility assessment dated [DATE] showed she has no cognitive impairment and requires substantial to maximum assistance with eating. R8's weight was recorded in her medical record as follows: 11/23/23 she weighed 113 lbs, on 12/4/23 she weighed 89 lbs, and as of 1/24/24 she weighs 91 lbs (19.47% weight loss over 2 months). R8's January 2024 Physician Order sheet showed nutritional supplements including 2.0 Calorie Supplement, Magic…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-01-19 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement interventions to prevent the worsening of pressure ulcers, failed to perform weekly assessments and measurements of a pressure wound, and failed to perform scheduled dressing changes for a pressure ulcer for 1 of 3 residents (R1) reviewed for pressure ulcers. These failures resulted in the deterioration and increase in size of R1's pressure ulcer from a stage 3 to unstageable. The findings include: R1's admission assessment showed he was admitted to the facility on [DATE]. R1's face sheet showed he has diagnoses of age-related physical debility, mixed hyperlipidemia, Parkinson's Disease, Type 2 Diabetes Mellitus, Benign Prostatic Hyperplasia, Hypertension, and muscle weakness. R1's 12/20/23 facility assessment to determine risk for skin breakdown showed R1 to be a high risk. This assessment showed the interventions in place for R1 at that time was a pressure relieving device in his chair and a turning and repositioning program.…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-01-19 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a catheter was maintained per physician orders, failed to ensure orders were in place for a resident with a catheter, and failed to provide catheter care for 2 of 3 residents (R1 and R4) reviewed for indwelling catheters. This failure resulted in R1 being diagnosed with a urinary tract infection on 1/16/24. The findings include: 1. R1's admission assessment showed he was admitted to the facility on [DATE]. R1's face sheet showed he has diagnoses of age-related physical debility, mixed hyperlipidemia, Parkinson's Disease, Type 2 Diabetes Mellitus, Benign Prostatic Hyperplasia, Hypertension, and muscle weakness. R1's care plan initiated 8/1/23 showed, The resident has a foley catheter: Neurogenic bladder, terminal condition . Catheter care every shift . On 1/16/24 at 12:18 PM, V11 (R1's Daughter) said she feels her father is not getting the care he needs for his catheter. V11 said her dad's catheter is supposed to be changed every two…

  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 · G2023-12-08 · tag F0835 — failed to run the facility competently — isolated
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to have a full time Administrator at the facility which contributed to deficient practices in the facility. This failure resulted in residents not receiving necessary care and services including nursing assessments, pain assessments, and pain documentation. The facility failed to follow their own policies and procedures and failed to ensure staff were trained upon hire and annually on the use of facility equipment. This has the potential to affect all 31 residents in the facility. The findings include: The Facility Data Sheet dated 12/1/23 showed the facility had a census of 31 residents. On 12/1/23 upon entry to the facility they did not have an Administrator and the Corporate Administrator overseeing the building was not onsite. On 12/1/23 at 9:15 AM, V2 DON (Interim Director of Nursing) stated the facility has not had an Administrator for 2-3 weeks. V2 stated V22 (Corporate Administrator) was over the building. V2 stated the DON was moved to another facility 1 week ago. V2 stated she is acting DON but is also…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-10-06 · tag F0675 — failed to support quality of life — isolated
  Honor each resident's preferences, choices, values and beliefs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a deaf resident with a mode of meaningful communication for 1 of 6 residents (R1) reviewed for quality of life in the sample of 6. This failure resulted in R1 being unable to communicate with his friends in the deaf community, as well as his Care Services Coordinator. R1 was unable to receive counseling services for several months and showed signs of depression and isolation. The findings include: On 10/5/23 at 9:30 AM, R1 was lying in bed, with his head covered. R1's blinds were closed and the room was dark. R1 remained in his dark room until the noon meal. At 12:30 PM, the surveyor, V8 (R1's POA), and V9 (Ombudsman) entered R1's room. R1 was pulling at a thick mattress that was resting against his bed. R1's TV was connected to a small box, with wires extending to the ceiling. The wires extended to the ceiling and across the room, into the wall. R1's electronic device, under the TV, would flash lights. V8 said, It looks like 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-10-06 · tag F0745 — failed to provide medically-related social services — isolated
  Provide medically-related social services to help each resident achieve the highest possible quality of life.
  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 medically necessary social services to a deaf resident with a history of schizoaffective disorder for 1 of 6 residents (R1) reviewed for medically necessary social services in the sample of 6. This failure resulted in R1 becoming depressed, lonely, and isolated. The findings include: On 10/5/23 at 9:30 AM, R1 was lying in bed, with his head covered. R1's blinds were closed, and the room was dark. R1 remained in his dark room until the noon meal. At 12:30 PM, the surveyor, V8 (R1's POA), and V9 (Ombudsman) entered R1's room. R1 was pulling at a thick mattress that was resting against his bed. R1's TV was connected to a small box, with wires extending to the ceiling. The wires extended to the ceiling and across the room, into the wall. R1's electronic device, under the TV, would flash lights. V8 said, It looks like the video calling system is ringing, but he can't answer it. It's V19 (R1's Care Service Coordinator) calling. V8 signed…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-06-15 · 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 maintain a safe environment by ensuring a resident's previous room was locked while being repaired. This applies to 1 of 3 residents (R2) reviewed for safety in the sample of 8. The findings include: On 6/15/26 at 9:29 AM, R2 was sitting up in her wheelchair in her room. She stated, she has had a couple of falls out of her wheelchair. The facility's May fall log shows, R2 had a fall on 5/13/26. She attained an abrasion for sliding out of the wheelchair. On 6/15/26 at 9:55 AM, V3 Licensed Practical Nurse (LPN) stated, she was the nurse working 5/13/26. She heard R2 screaming but she was 1:1 with another resident and couldn't leave. V7 housekeeping was walking by so she asked her to please go see why R2 was screaming. V7 came back saying, R2 had fallen. At that time, she was able to go check on R2. V6 Certified Nursing Assistant (CNA) was with her. They found R2 in a different room down the hall from her own room. She had fallen into a hole in the floor. Her legs were in the hole. She had a small rug-burn like…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-04 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review the facility failed to ensure catheter care was completed in a manner to prevent contamination for a resident with a history of urinary tract infections (R4), for 1 of 3 residents reviewed for indwelling urinary catheters in the sample of 4.The findings include: R4's Face Sheet shows she has diagnoses including dementia and neuromuscular dysfunction of the bladder.R4's Physician Order summary and active Care Plan show R4 has an indwelling urinary catheter and catheter care should be provided every shift and immediately after an incontinent episode. A facility provided list of residents who had Urinary Tract Infections (UTI's) shows that R4 had UTI's requiring antibiotic treatment on 1/3/26 and again on 2/18/26.On 3/4/26 at 11:13 AM V4 and V5 both Certified Nursing Assistants (CNA's) were providing catheter care to R4. V4 had a basin of soapy water and a basin of plain water, V4 said one basin was for washing and the other was to rinse after they clean the area. R4 had stool present so V4 took a washcloth and cleaned the stool from…

  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 before2025-04-18 · 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 maintain a safe walking environment for a resident at risk for falls for 1 of 3 residents (R3) reviewed for falls in the sample of 11. The findings include: On 4/16/25 at 12:07 PM, R4 was sitting on her bed. R4 said she usually goes to the dining room for meals, but was feeling a little irritated today. R4 said she usually sits in a table closer to the sliding, glass door. R4 said the floor is messed up in the dining room and she saw a male resident fall about a month ago because of it. R4 stated, The floor is coming up in some places and the leg of her chair gets caught up in it. I've told everyone about it because I don't want anyone to get hurt. R4 said the facility told her that the floor was going to be replaced, but nothing has happened and it's been a month. R4's facility assessment dated [DATE] showed she was cognitively intact. On 4/16/25 at 12:09 PM, the surveyor toured the dining room area. The room has a small half wall at one…

  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 before2025-04-18 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
  Make 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain the dining room floor in a safe, functional condition for 9 ambulatory residents (R2, R3, R4, R6, R7, R8, R9, R10, R11) reviewed for a safe, functional environment in the sample of 11. The findings include: On 4/18/25, V1 (Administrator) provided a list of residents that were ambulatory to the dining room. This list included R2, R3, R4, R6, R7, R8, R9, R10 and R11. On 4/16/25 at 12:09 PM, the surveyor toured the dining room area. The room has a small half wall at one end and a sliding, glass door at the opposite end. There were 2 visible seams in the laminate flooring that ran the length of this room. Along the visible seams there were random patches of a brown, sticky substance (floor glue combined with floor debris) and tiny nails that were ran along both sides of the seams in other areas. Both seam lines had various areas where the laminate flooring was puckering (each side of the seam was lifted from the surface and posed 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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-12-05 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review the facility failed to provide a comfortable home like dining experience for two of three residents (R21 and R7) reviewed for clean, comfortable homelike in the sample of 13. The findings include: On 12/4/2024 at 8:20 AM R21 and R7 were observed eating their breakfast in the small dining room near the sliding glass doors leading to the patio. R5 came and opened the patio doors to go outside to fill the bird feeders, leaving the doors open and cold air was blowing into the dining room. R21 was observed pushing himself away from his breakfast and saying,It's too cold to sit here anymore. R21 had over half his breakfast left. R7 was observed glancing over his shoulder several times to look at the open doors. R7 then left the dining room with food still on his plate. Several facility staff were observed walking past the small dining room and the open door and some were heard saying how cold it was. At 8:28 AM, V6 (Registered Nurse/RN) went and got R21 who had wheeled himself around the corner to get away from the cold, and brought him 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-12-05 · 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 resident was transferred in a safe manner (R8) and failed to ensure a resident was assessed for safe smoking (R18) for 2 of 4 residents reviewed for safety in the sample of 13. The findings include: 1. R8's face sheet printed on 12/4/24 showed diagnoses including but not limited to cerebral infarction, Parkinson's disease, depression, vomiting without nausea, and dysphagia (difficulty swallowing). R8's facility assessment dated [DATE] showed no cognitive impairment and partial to moderate staff assistance for eating. The same assessment showed full staff dependence for transfers. R8's December 2024 order summary report showed an order start dated on 9/30/24 for: Because of potential for injury please make this patient a Mechanical lift only . On 12/4/24 at 9:03 AM, V11 and V16 (Certified Nurse Aides) transferred R8 from her bed to the wheelchair. The aides sat R8 on the edge of the bed and held her underneath her arms. R8 appeared…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-12-05 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure an indwelling catheter drainage bag was maintained in a manner to prevent contamination for 1 of 3 residents (R4) reviewed for catheters in the sample of 13. The findings include: R4's admission record shows he was admitted to the facility on [DATE] with multiple diagnoses including multiple sclerosis, flaccid neuropathic bladder, acute kidney failure, history of UTI's (Urinary Tract Infections). The facility's 10/21/24 annual resident assessment for R4 shows he has an indwelling urinary catheter. The 10/31/24 care plan documents he is at risk for UTI's due to indwelling urinary catheter. On 12/03/24 at 10:02 AM, R4 was observed lying in bed. He had an indwelling catheter bag on the side of his bed, and it was resting on the floor. On 12/03/24 at 11:27 AM, V11 and V12 (Certified Nursing Assistants) said catheter drainage bags should not be on the floor, due to infection issues. The drainage bag should be in a dignity bag. V11 and V12…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-12-05 · 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 observation, interview and record review the facility failed to initiate an antibiotic when ordered for 1 of 1 residents (R19) reviewed for pharmacy services in the sample of 13. The findings include: R19's order summary sheet documents he was admitted on [DATE] with multiple diagnoses including multiple sclerosis, and neuromuscular dysfunction of bladder. The orders show he has long term use of a urinary catheter. The after visit summary of the local emergency room shows R19 was seen on 9/20/24 for a fever and abdominal pain. He had blood tests and a urine culture completed. He was given IV (intravenous) antibiotics, and discharged with an order for cefpodoxime 200 mg (milligrams) twice daily for 10 days. The medication was to start on 9/20/24 and end on 9/30/24. The facility order for cefpodoxime was input on 9/21/24 at 1:20 AM. The September MAR (Medication Administration Record) shows the medication was not started until 9/21/24. On 12/05/24 at 10:13 AM, V3 (Director of Nursing) said at that time…

  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 · D2024-12-05 · 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 medications as ordered. There were 25 opportunities with two errors resulting in a 8% error rate. This applies to one of four residents (R23) observed in the medication pass. The findings include: On 12/4/2024 at 8:47 AM, V6 (Registered Nurse/RN) was observed giving R23 his morning medications during the medication pass observation task. The Physician Orders dated 12/2024 shows an order for pantoprazole 40 mg (milligrams) (medication for heartburn) to be given two times a day at 8:00 AM, and 5:00 PM and polyethylene glycol 17 grams ( medication for constipation) at 8:00 AM. These two medications were not given to or offered to R23 during the medication pass on 12/4/24 by V6. On 12/5/24 at 9:00 AM, V4 (Nurse Consultant) and V3 (Director of Nursing) said a resident's medication should be given as ordered by the physician. The facility face sheet shows R23 was admitted to the facility with alcoholic hepatitis, alcoholic cirrhosis and esophageal varices. The facility policy updated on 9/2023 for…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-12-05 · tag F0842 — failed to keep accurate, complete medical records — isolated
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted 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 use the current electronic health records (EHR) medication administration record (MAR) to administer medications to the residents. This applies to 3 of 3 residents (R21, R18 and R23) reviewed for medical records in the sample of 13. The findings include: On 12/3/24 at entrance into the facility at 8:30 AM, V1 (Administrator) said the facility had just gone live with the new EHR at midnight on 12/3/2024. On 12/4/24 between the hours of 8:20 AM to 8:47 AM, V6 (Registered Nurse/RN) was observed passing medications to R21, R18 and R23 and was using the past EHR's MAR. V6 said she had never been trained on how to pass medications and document in the facilities current EHR, so she was using what she knew how to do. V5 (Licensed Practical Nurse), who was in the facility to assist the staff on the use of the new EHR, observed V6 using the old EHR, asked V6 why was she using the old EHR and was told by V6 she did not know how to use the new system. V5 walked away from V6 and allowed her to continue using the old system…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“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

$302,370 in federal fines across 6 penalties. 4 Medicare payment denials on record.

• $17,345 — penalty dated 2026-02-05
• $74,159 — penalty dated 2024-12-05
• $16,801 — penalty dated 2024-07-03
• $35,438 — penalty dated 2024-07-03
• $39,998 — penalty dated 2024-01-19
• $118,629 — penalty dated 2023-09-14
• Medicare payment denial — starting 2026-02-28 for 14 days
• Medicare payment denial — starting 2024-12-27 for 35 days
• Medicare payment denial — starting 2024-07-27 for 75 days
• Medicare payment denial — starting 2023-10-31 for 64 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 LINEAGE 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 19 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

3 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.

About 73% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $149K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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