Big Meadows
1000 Longmoor, Savanna, IL 61074 · For profit - Corporation · 83 certified beds · (815) 273-2238 Medicaid only — no Medicare
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $4,500 in federal fines (most recent 2025-02-25)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 23.4% | 13.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 6.8% | 6.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 8.1% | 54.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.9% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 26.0% | 14.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 28.3% | 18.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 10.3% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 19.7% | 20.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 20.4% | 21.7% | 17.1% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.02 | 2.02 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.06 | 2.22 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.09 therapist hours per resident per day in 2026Q1 — more than 5% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 83 beds and averages 59.6 residents a day — about 72% occupied, or roughly 23 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.31 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.28 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 3.22 hrs/resident/day on weekends vs 3.34 on weekdays — 4% thinner on weekends. RN hours go from 0.57 to 0.45 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 38% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
30 citations, most serious first. The 15 most serious are shown; the remaining 15 are one tap away and print in full.
- Immediate jeopardy · Jcited before2023-11-14 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify a resident's physician of a change in condition for greater than 24 hours. This failure resulted in a decline in R1's condition leading to hospitalization for acute hypoxic respiratory failure, sepsis, and suspected hypoxic brain injury. This applies to 1 (R1) of 3 residents reviewed for change in condition in the sample of 6. The findings include: The Immediate Jeopardy began on 11/4/23 when R1 began experiencing increased incontinence, assistance with transfers, assistance with feeding. V1 (Administrator) was notified of the Immediate Jeopardy on 11/14/23 at 10:15AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 11/14/23, but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. R1's electronic face sheet printed on 11/8/23 showed R1 had diagnoses including but not limited to 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.
- Immediate jeopardy · J2023-11-14 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to identify, assess, and monitor a resident (R1) with significant respiratory changes. This failure resulted in R1 being hospitalized with acute respiratory failure, septic shock related to urinary tract infection and pneumonia, and suspected hypoxic brain injury. R1 expired in the hospital as a result of his illnesses. This failure applies to 1 of 3 residents reviewed for oxygen therapy in the sample of 6. The findings include: The Immediate Jeopardy began on [DATE] when R1 was struggling to breathe and placed on oxygen. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 10:15AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. R1's electronic face sheet printed on [DATE] showed R1 had diagnoses including but 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.
- Actual harm · G2025-02-25 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to implement care planned interventions to reduce a dementia resident's anxiety and aggressive behaviors. This failure resulted in R49 fracturing a finger on his left hand after punching a wall. This failure applies to 1 of 9 residents (R49) reviewed for dementia care in the sample of 16. The findings include: A facility incident report dated 2/18/25 showed R49 became agitated during cares and swung out at CNA (certified nursing assistant). While swinging at the CNA, he hit the wall as he was in bed and the bed was pushed up against the wall. X-ray was completed and shows acute fracture of proximal phalanx 3rd finger with mild deformity . R49's admission record dated 8/30/24 showed R49 had diagnoses of anxiety and dementia with behavioral disturbances. R49's behavior note dated 12/20/24 showed R49 started hitting staff, was at the front door hitting the glass after becoming agitated and anxious. R49's behavior note dated 1/7/25 showed, Resident becomes very anxious, sometimes agitated and restless around 6 or 7…
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.
- Actual harm · Gcited before2024-02-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to transport a resident in a wheelchair with her feet on the foot pedals. This failure resulted in R1 sustaining a fracture to her right femur. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 3. The findings include: R1's admission Record (Face Sheet) showed an original admission date of 11/1/23 with diagnoses to include: cervical vertebra fracture (bones in the neck, was her admitting diagnosis), osteoporosis (decreased bone strength) without current pathological fracture (no fractures due to her osteoporosis), arthritis, cognitive communication deficit, lack of coordination, difficulty in walking, lack of coordination, need for assistance with personal care, and adult failure to thrive. The facility's final incident report submitted on 2/14/24 showed .it appears that [R1] moved her foot from the foot pedal while being assisted from the dining room causing her foot to touch the floor. The staff member stopped…
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.
- Actual harm · G2024-02-29 · tag F0697 — failed to manage pain — isolatedProvide 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
Based on observation, interview, and record review the facility failed to manage a resident's (R1) pain when she was known to have a fractured leg and she was transferred without her immobilizer. The facility also failed to provide pain medication for resident (R1) with fractured leg prior to transferring her out of bed. This failure resulted in R1 experiencing excruciating pain. This applies to 1 of 3 residents reviewed for pain in the sample of 3. The findings include: R1's admission Record (Face Sheet) showed an original admission date of 11/1/23 with diagnoses to include: cervical vertebra fracture (bones in the neck, was her admitting diagnosis), osteoporosis (decreased bone strength) without current pathological fracture (no fractures due to her osteoporosis), arthritis, cognitive communication deficit, lack of coordination, difficulty in walking, lack of coordination, need for assistance with personal care, and adult failure to thrive. The facility's video footage showed on 2/13/24 at approximately 6:00 PM (time was adjusted due to inaccuracy of the camera timestamp) V11…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-05-14 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that food was served at palatable temperatures. This applied to residents reviewed for dining/palatable food which included R33, R37, R66 and the resident council in the sample of 31.The findings include:On 5/12/26 at 10:13 AM, R33 stated she eats in her room and in the dining room. R33 stated her food is served cold all the time.On 5/12/26 at 10:21 AM, R66 stated he eats in his room and his food that is supposed to be warm is cold by the time it gets to him. R66 stated the staff just drop his food tray off and leave. R66 stated he had told staff about and he was not aware he could have staff warm up his food.On 5/13/26 at 8:39 AM, R37 stated that sometimes her hot food is served cold. R37 stated yesterday when she received her lunch tray her ice cream was melted. R37 stated she doesn't know why that is and that she guesses it is just the way it is.On 5/13/26 at 10:34 AM, during the resident council meeting the residents stated that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide shower assistance for a resident dependent upon staff for assistance. This applies to 1 of 3 residents (R25) reviewed for activities of daily living in the sample of 31. The findings include:R25's admission Record (Face Sheet) showed he was admitted to the facility on [DATE] with diagnoses to include but not limited to shortness of breath, depression, and arthritis. R25's 3/5/26 Quarterly Minimum Data Set (MDS) showed he was cognitively intact with a Brief Interview for Mental Status score of 13 out of 15. The MDS showed he required partial/moderate assistance for showering/bathing. On 5/12/2026 at 9:40 AM, R25 stated, .Last Friday (5/8/26) I didn't get a shower and it was about two weeks before I finally got one. Tuesday I get a shave and Friday I get a shower and a shave. It doesn't happen often, but it doesn't happen. They promised me twice on Friday, they promised me at 2:00 PM they would do it then they promised me again at 3:00 PM and I…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-14 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 assess a resident experiencing a change in condition. This applies to 1 of 3 residents (R3) reviewed for changes in condition in the sample of 31. The findings include:R3's admission Record (Face Sheet) showed an admission date of 10/13/25 with diagnoses to include but not limited to heart failure, bipolar disorder, anxiety, and type 1 diabetes. R3's 3/17/26 Quarterly Minimum Data Assessment (MDS) showed she was not comatose, she could hear adequately, she could make herself understood, she could understand others, and she had adequate vision. R3's MDS showed she had moderate cognitive impairment with a Brief Interview for Mental Status score of 8 out of 15 (15 being a perfect score, cognitively intact). The BIMS showed she was able to repeat three words said to her, she correctly answered the month and the day of the week. On 5/12/2026 at 11:40 AM, R3 was in bed, on her back, and in hospital gown. R3 opened her eyes; however, she could not lock eyes and did not respond to any questions. On 5/12/2026 at 12:47…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-14 · tag F0687 — failed to care for feet properly — isolatedProvide appropriate foot care.
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 footcare including monitoring and treatment was provided after a residents toe was cut during a podiatry visit for 1 of 3 residents (R37) reviewed for foot care in the sample of 31.The findings include:On 5/13/26 at 8:39 AM, R37 stated the doctor cut her toenail too short last time that she had her toenails trimmed. R37 stated there was bleeding to the big toe on the left foot after her toenails were cut. R37 stated she hasn't had her toenails cut since this happened.On 5/13/26 at 1:19 PM, V2 (Director of Nursing/DON) stated she was not aware of R37's toe being cut by the podiatrist and that it wasn't reported to her.On 5/14/26 at 8:30 AM, V2 (DON) stated she investigated R37 and the podiatrist cutting her toe. V2 stated she found a secure conversation written by the nurse to the resident's primary physician on 3/9/26 that showed R37 was seen by the podiatrist, her toenails were clipped, the left big toe was bleeding and wrapped by the podiatrist. The note stated the family wanted to use a Dremel or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure a gait belt was applied and used correctly during a transfer and failed to ensure a bed alarm was turned on for 2 of 2 residents (R37 & R4) reviewed for safety in the sample of 31.The findings include:1. On 5/12/26 at 12:56 PM, V11 (Certified Nursing Assistant/CNA) took a gait belt and put it loosely around R37's lower chest are slightly above her hanging breasts. V11 assisted R37 to transfer from the wheelchair to the toilet and the gait belt moved up under R37's arms. V11 stated that she tries to put the gait belt under R37's breast but sometimes places it on the resident's chest just under her armpits because it is more comfortable. V11 stated R37 transfers with supervision and did not need the gait belt. V11 stated a resident that is a one assist for transfers needs a gait belt.On 5/13/26 at 1:19 PM, V2 (Director of Nursing/DON) stated gait belts should be applied around a resident's waist. The gait belt should not be around the chest and under the residents' arms. That is not appropriate to be up…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-14 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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 urinary catheter was maintained in a manner to prevent cross contamination for 1 of 2 residents (R8) reviewed for catheters in the sample of 31. The findings include:R8's face sheet showed he was admitted to the facility 2/26/26 with diagnoses to include cerebral infarction due to embolism of bilateral anterior cerebral arteries dysphagia, hypertension, acute kidney failure with tubular necrosis, hypokalemia, retention of urine, and obstructive and reflux uropathy. R8's facility assessment dated [DATE] showed he has an indwelling urinary catheter. R8's Care Plan initiated 3/3/26 showed, [R8] has an indwelling foley catheter. Observe for any kinds in tubing, that it is flowing properly and positioned correctly at bedside, when up in chair, wheelchair, etc. R8's May 2026 Physician Order sheet showed, . Foley Catheter 16 FR with 30 cc [NAME] to closed drainage system. Diagnosis of Urinary Retention.On 5/12/2026 at 10:47…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-14 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 administer insulin in accordance with manufacturer's instructions. This applies to 3 of 3 residents (R6, R38, and R43) reviewed for insulin in the sample of 31. The findings include:1. R6's admission Record (Face Sheet) showed he was admitted to the facility on [DATE] with diagnoses to include but not limited to diabetes type 2, dementia, and depression. R6's May 2026 Medication Administration Record (MAR) showed he received 12 units of long-acting insulin every 12 hours. On 5/13/2026 at 7:56 AM, V6 (Registered Nurse/RN) prepared R6's long-acting insulin multidose injection pen (commonly referred to as an insulin pen). V6 attached the needle to the pen; she did not wipe the rubber seal with alcohol. V6 then dialed the pen to 12 units of insulin. V6 did not prime the insulin pen. V6 then wiped R6's right lower abdomen with an alcohol wipe, held the pen to his skin, depressed the plunger, and held the plunger for less than two seconds. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-06 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident was treated with respect and dignity and not subjected to verbal abuse from a facility employee for 1 of 3 residents (R3) reviewed for Resident Rights and abuse in the sample of 3.The findings include:R3's admission record shows she was admitted to the facility on [DATE]. The quarterly resident assessment and care screening of 11/24/25 documents R3 to have moderate cognitive impairment. The same document shows she is dependent on staff for activities of daily living and for mobility.On 12/6/25 at 1:30 PM, R3 said the incident happened a while ago, and does not recall the exact words, but remembers the girls were nasty towards her while providing care. R3 said the way they spoke to her was disrespectful. She recalled the staff saying, 'Well, if you weren't so old,' just nasty things. I told her to knock it off and she did not listen, and said, 'I don't know why they send you (old) people here.' The facility's investigation showed a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-10-30 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to conduct and document an assessment for a resident following an unwitnessed fall for 1 of 3 residents (R1) reviewed for quality of care in the sample of 3.The findings include:R1's admission record shows he was admitted to the facility on [DATE] and resided on the connection dementia unit. The same document lists his diagnoses including unspecified dementia.The facility's 10/27/25 incident report documents at approximately 7:40 PM R1 was found on the floor. He was lying on his right side in front of the TV. There was a pool of blood at his head, he was yelling and reaching up for help. He denied pain, stating he just wanted to get up. Cold compress to head and was assisted from the floor to a chair with the gait belt. At that time, he complained of right hip pain, unable to bear weight right hip. The Power of Attorney (POA) was notified, and he was sent to the emergency room for evaluation. The note includes vital signs but no range of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-02-25 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's 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 meaningful activities to dementia residents for 4 of 10 residents (R39, R30, R45, R36) reviewed for activities in the sample of 16. The findings include: 1. R39's Physician Order Sheet (POS) dated 2/25 show R39 has diagnosis of dementia. R39's care plan with review date of 1/21/25 documents, R39 prefers individual 1:1 activities, at times may observe/join a group activity. R39 enjoys walking halls, relaxing in his room, common area, reminiscing, watching TV, visiting with family, listening to music, going outdoors, observing dice/card games, bingo, painting arts and crafts. On 2/23/25, At 10AM, 11AM, 11:37 AM and 12 PM, R39 was up and down the hallways wandering back and forth on both E and F wings in the Dementia Unit. Staff were saying hi to R39. R39 would enter other resident's room, then staff would redirect R39 don't go in that room. R39 was not offered to engage in any activity. R39 had lunch around 12:30 PM. Then at 1PM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 15 citations
- Potential for harm · E2025-02-25 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to follow the pureed menu for 8 of 8 residents (R1, R2, R7, R11, R13, R18, R33, and R46) reviewed for pureed menu in the sample of 16. The findings include: A facility provided list printed on 2/24/24 showed R1, R2, R7, R11, R18, R33, and R46 were on a pureed diet. The same list showed R13 was on a liquidized pureed diet. The pureed menu for 2/24/25 showed residents on pureed and liquidized pureed diets were to receive pureed BBQ turkey, pureed creamed corn, pureed cornbread, and pureed cake. On 02/24/25 at 10:02 AM, V20 (Cook) was observed making the pureed meal. V20 pureed the BBQ turkey, creamed corn, and dessert. V20 was not observed making pureed corn bread nor was corn bread added to the BBQ turkey or creamed corn. On 02/24/25 at 11:17 AM, V20 started to plate the pureed meal. There was no container of pureed cornbread on the serving steam table. V20 plated R1, R7, R11, and R13's pureed meals by serving them pureed BBQ turkey, pureed creamed corn, and pureed dessert. R1, R7, R11, and R13 did not received…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-25 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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 a facility bed hold policy was in the resident packet of information for a resident who was transferred to the hospital for 1 of 1 resident (R33) reviewed for hospitalizations in the sample of 16. The findings include: The facility' census list for R33, shows on 2/16/25, R33 was transferred out to the hospital. R33's progress noted dated 2/16/25, shows R33 had a change in condition where her oxygen saturations dropped to 86 percent. The nurse practitioner was notified with orders to send to emergency room for evaluation. R33's POA was notified, paperwork was faxed to the hospital. On 2/25/25 at 8:26 AM, V17 (Registered Nurse) stated there is a packet of paper which goes with resident to the hospital, face sheet, POA paperwork, insurance, POLST, meds and diagnoses. We fax the packet to the hospital, and we give the packet to EMS (Emergency Medical Services). V17 was not sure if bed hold went with resident. V1(Administrator) would know. V17 showed this surveyor the packets of information which went with the residents.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-25 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 to ensure speech therapy recommendations were implemented for a resident with moderate oral/pharyngeal dysphagia. This applies to 1 of 3 residents (R161) reviewed for safety in the sample of 16. The findings include: On 2/23/24 at 12:45 PM, a sign posted on R161's door for droplet/contact precautions. R161 was in her room lying in bed at approximately 30 degrees. R161's noon meal on her bedside table included country fried steak cut up, veggies and mashed potatoes. R161's diet card lists a regular diet. On 2/24/25 at 12:50 PM, R161 was in her room lying in bed at 30 degrees. Her noon meal on her bedside table included a BBQ pork sandwich, corn, and coleslaw. Regular liquids on her bedside table. On 2/24/25 at 12:58 PM, V8 (Licensed Practical Nurse) said R161 has not been doing well, she has influenza and was recently sent out to the hospital and has been declining. She is on a regular diet, has poor appetite and is not aware of R161 having any problems swallowing. On 2/25/25 at 9:54 AM, V1 (Administrator) said speech…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-25 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident's adaptive equipment was functioning for 1 of 9 residents (R10) reviewed for restorative in the sample of 16. The findings include: On 02/23/25 at 11:16 AM, R10 was sitting in his wheelchair near the nurse's station. His left arm was dangling next to his side. The wheelchair arm trough attached to the left wheelchair arm was bent over with the bottom of the trough facing away from the resident. R10 stated he does not use it (arm trough) because it was broken. It had been broken for a few months. He told the staff and they said they would fix it, not sure when that is going to happen. R10 explained he had a stroke which affected his left side. R10 then proceeded to self-propel himself using his right foot down the hallway. R10's Facility assessment dated [DATE] shows diagnoses to include stroke and hemiplegia. R10's has impaired range of motion on his left side and is cognitively intact. R10's current care plan shows R10…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-25 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure staff implemented enhanced barrier precautions to prevent the spread of infection for 2 of 16 residents (R2, R45) reviewed for infection control in the sample of 16. The findings include: 1. On 2/24/25 at 9:22 AM, there was no sign posted on R2's door for enhanced barrier precautions. V24 (Certified Nursing Assistant/CNA) donned gloves and did not wear a gown while providing incontinence care to R2. An open pressure ulcer was observed on R2's coccyx. On 2/24/25 at 2:03 PM, V3 (Assistant Director of Nursing/Infection Control Preventionist) said R2 was on isolation for influenza, and they discontinued her isolation. She said R3 has a wound and should be on enhanced barrier precautions, staff should wear gown and gloves when providing direct care. R2's Physician Order Sheets dated February 2025 does not show orders for enhanced barrier precautions. The P.O.S. shows orders for treatment orders for right coccyx wound. 2. On 02/23/25 at 9:15 AM, R45 was in his room alert and pleasant. An Enhance Barrier…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-29 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to notify a resident's (R1) Power of Attorney (V3) of an incident with a wheelchair and the subsequent X-ray order. This applies to 1 of 3 residents (R1) reviewed for notification in the sample of 3. The findings include: R1's admission Record (Face Sheet) showed an original admission date of 11/1/23 with diagnoses to include: cervical vertebra fracture (bones in the neck, was her admitting diagnosis), osteoporosis (decreased bone strength) without current pathological fracture (no fractures due to her osteoporosis), arthritis, cognitive communication deficit, lack of coordination, difficulty in walking, lack of coordination, need for assistance with personal care, and adult failure to thrive. The facility's final incident report submitted on 2/14/24 showed .it appears that [R1] moved her foot from the foot pedal while being assisted from the dining room causing her foot to touch the floor. The staff member stopped immediately when this happened and called the nurse stat. The report showed an x-ray was ordered and 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.
- Potential for harm · D2024-02-29 · tag F0776 — isolatedProvide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to enter an order with the facility's imaging service for several hours after an incident involving a wheelchair transportation. This applies to 1 of 3 residents (R1) reviewed for imaging in the sample of 3. The findings include: R1's admission Record (Face Sheet) showed an original admission date of 11/1/23 with diagnoses to include: cervical vertebra fracture (bones in the neck, was her admitting diagnosis), osteoporosis (decreased bone strength) without current pathological fracture (no fractures due to her osteoporosis), arthritis, cognitive communication deficit, lack of coordination, difficulty in walking, lack of coordination, need for assistance with personal care, and adult failure to thrive. The facility's final incident report submitted on 2/14/24 showed .it appears that [R1] moved her foot from the foot pedal while being assisted from the dining room causing her foot to touch the floor. The staff member stopped immediately when this happened and called the nurse stat. The report showed an x-ray was ordered and 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.
- Potential for harm · D2024-02-20 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
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 implement their abuse policy by not reporting and not investigating an allegation of abuse for one of seven residents (R1) reviewed for abuse in the sample of seven. The findings include: R1's admission Record shows she was admitted to the facility on [DATE] with diagnoses including: heart failure, arthritis, dermatitis, lymphedema, muscle weakness, lack of coordination, urinary tract infection, and pain. R1's Minimum Data Set, dated [DATE] shows she is cognitively intact. On February 15, 2024 at 8:55 AM, R1 said an incident occurred on January 30, 2024. R1 said V5 (Certified Nursing Assistant/CNA) came into R1's room and asked her what time R1 wanted to get up for the day. R1 told V5 that she wasn't sure. I haven't even had my coffee yet. R1 said that V5 was trying to fit R1 into V5's schedule for the day. R1 said that V5 told her that R1 wouldn't get care if V5 did not do it. V5 told R1 that R1 wouldn't be able to get up from 11:00 AM-12:20 PM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-20 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of abuse to the abuse coordinator for one of seven residents (R1) reviewed for abuse in the sample of seven. The findings include: R1's admission Record shows she was admitted to the facility on [DATE] with diagnoses including: heart failure, arthritis, dermatitis, lymphedema, muscle weakness, lack of coordination, urinary tract infection, and pain. R1's Minimum Data Set, dated [DATE] shows she is cognitively intact. On February 15, 2024 at 8:55 AM, R1 said an incident occurred on January 30, 2024. R1 said V5 (Certified Nursing Assistant/CNA) came into R1's room and asked her what time R1 wanted to get up for the day. R1 told V5 that she wasn't sure. I haven't even had my coffee yet. R1 said that V5 was trying to fit R1 into V5's schedule for the day. R1 said that V5 told her that R1 wouldn't get care if V5 did not do it. V5 told R1 that R1 wouldn't be able to get up from 11:00 AM-12:20 PM, because staff would be in the dining room…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-20 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a thorough investigation was completed in regard to an allegation of abuse for one of seven residents (R1) reviewed for abuse in the sample of seven. The findings include: R1's admission Record shows she was admitted to the facility on [DATE] with diagnoses including: heart failure, arthritis, dermatitis, lymphedema, muscle weakness, lack of coordination, urinary tract infection, and pain. R1's Minimum Data Set, dated [DATE] shows she is cognitively intact. On February 15, 2024 at 8:55 AM, R1 said an incident occurred on January 30, 2024. R1 said V5 (Certified Nursing Assistant/CNA) came into R1's room and asked her what time R1 wanted to get up for the day. R1 told V5 that she wasn't sure. I haven't even had my coffee yet. R1 said that V5 was trying to fit R1 into V5's schedule for the day. R1 said that V5 told her that R1 wouldn't get care if V5 did not do it. V5 told R1 that R1 wouldn't be able to get up from 11:00 AM-12:20 PM, because staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident did not fall off the bed when being turned. The facility failed to assess and care plan a resident for the use of a nicotine vaping device for 2 of 2 residents (R19 & R17) reviewed for safety and supervision in the sample of 17. The findings include: 1. On 1/17/24 at 8:26 AM, R19 was laying on her back in the middle of her bed with the head of her bed elevated. R19's bed was not in a low position. R19 had a large burgundy mark to her forehead with purple discoloration around the area. R19 had purple bruising to the inner corners of her eyes. R19 was awake and making noises. R19 did not respond to her name or questions. The Nurse's Note dated 1/15/24 for R19 showed, Nurse called stat (immediately) to the resident's room, CNA (Certified Nursing Assistant) in with the resident, and resident laying on her right side on the floor next to the bed. The CNA stated that she was getting the resident ready to get up for lunch and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-18 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, and record review the facility failed to ensure a controlled medication was behind 2 locks in the medication room. This applies to 1 of 1 resident (R35) reviewed for controlled medication storage in the sample of 17. The findings include: On 1/18/24 at 12:39 PM, the medication room on the dementia unit had a refrigerator that did not have a lock on it while it held liquid Lorazepam ordered for R35. The refrigerator had holes where the lock use to be, but it was removed. On 1/18/24 at 12:39 PM, V4 (Assistant Director of Nursing) said, all controlled medication should be behind 2 locks. On 1/18/24 at 2:19 PM, V11 (Pharmacist) said, controlled substances should be behind 2 locks. V11 said, all controlled substances have the potential to be abused. The undated Medication Storage policy and procedure shows, Controlled medication must be stored in a manner to limit access and to facilitate reconciliation in accordance with the facility policies. Narcotics must always be stored under a double locking system.
- Potential for harm · Dcited before2024-01-18 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to prevent cross contamination of resident contact surfaces by not removing gloves after providing incontinence care before touching clean areas on the resident and resident contact surfaces for 1 of 1 resident (R9) reviewed for infection control in the sample of 17. The findings include: On 1/16/24 at 1:10 PM, V7 (Certified Nursing Assistant/CNA) and V8 (CNA) transferred R9 to bed to provide incontinence care. V7 and V8 had on gloves, removed the sling under R9 and then pulled her pants down. R9 had a wet incontinence brief on. V7 grabbed the no rinse foam cleanser from R9's nightstand, applied it to the washcloth and washed R9's groin and vaginal area. V7 discarded the soiled washcloth and picked up a clean towel from R9's nightstand and dried her groin and vaginal area. V7 did not change her gloves and helped turn R9 over onto her right side. V7 grabbed a clean washcloth from the nightstand, picked up the no rinse foam cleanser from the nightstand and applied it to the washcloth. V7 washed R9's buttocks and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-18 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 offer and administer pneumonia vaccinations for 3 (R26, R35, R51) of 5 residents reviewed for immunizations in the sample of 17. The findings include: 1. R35's face sheet showed an [AGE] year-old male with diagnosis of Alzheimer's Disease, hypertension, chronic ischemic heart disease, chronic kidney disease, malignant neoplasm of the prostate, peripheral vascular disease, and hypothyroidism. R35's face sheet showed admission to the facility on [DATE]. R35's immunization records showed he received a pneumococcal vaccine (Pneumovax 23) on 11/5/2002 and a pneumococcal conjugate (Prevnar 13) on 10/20/2014. R35's consent to administer pneumonia vaccine form was signed 12/2/20. R35's medical record showed no evidence of additional pneumonia vaccine administration since admission. 2. R51's face sheet showed a [AGE] year-old male with diagnosis of Alzheimer's Disease, chronic atrial fibrillation, hypertensive heart disease with heart failure, peripheral…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-04 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide the necessary care and services by not providing treatment for a resident with loose stools, failing to follow up on stool sample requests, and failing to update the physician for a resident with loose stools. This applies to 1 of 3 residents reviewed for nursing care in the sample of 4. The findings include: R1's admission Record (Face Sheet) showed he was admitted on [DATE] with diagnoses to include dementia, bladder cancer, diabetes, and diarrhea. R1's face sheet showed his onset date for diarrhea was 12/24/23, all other diagnoses listed above were present on admission. R1's 12/11/23 admission Minimum Data Set (MDS) showed severe cognitive impairment with a brief interview for mental status score of 7 out of 15. The MDS showed he required substantial assistance for transfers to the toilet and personal hygiene. R1's Progress Notes showed he was admitted to a local area hospital on [DATE] with diagnoses of Clostridioides difficile (C. diff, 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$4,500 in federal fines across 1 penalty.
- $4,500 — penalty dated 2025-02-25
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
What families pay in IL
CMS lists this home as Medicaid-certified only — it can accept Medicaid for long-term care, but it is not Medicare-certified, so Medicare will not pay for a short rehabilitation (“skilled nursing”) stay here. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 14E701. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-14, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.