Avenues At Quad Cities
1403 9th Avenue, Silvis, IL 61282 · For profit - Corporation · 63 certified beds · (309) 796-2600 Medicaid only — no Medicare
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its independent health-inspection rating is low (2/5)
- it did not file the payroll staffing data CMS requires — its 1 of 5 staffing rating is the rating CMS assigns for not reporting, not a measure of how many nurses are on the floor
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 21.4% | 13.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 0.0% | 6.3% | 5.4% | check this* — see note marked star below the table |
| Long-stay residents with a catheter left in their bladder | 2.5% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 64.3% | 54.2% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.0% | 3.1% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents on antianxiety or hypnotic medication | 13.3% | 18.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 70.6% | 91.8% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 3.7% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 24.3% | 20.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.0% | 21.7% | 17.1% | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Staffing
No payroll-based (PBJ) staffing hours are on file for this home — and the record suggests that is because it did not report them. CMS rates its staffing 1 of 5, which is the rating CMS assigns when a home does not report. Every Medicare-certified nursing home is required to submit its actual payroll data quarterly, and that submission is what makes staffing numbers auditable rather than a claim. A home that does not file is not the same as a home with no data yet: ask this home directly what its nurse-to-resident ratios and weekend RN coverage are, why its payroll data is not filed, and weigh the independent health-inspection score heavily in the meantime.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
27 citations, most serious first. The 14 most serious are shown; the remaining 13 are one tap away and print in full.
- Immediate jeopardy · J2025-02-04 · 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 interview, observation and record review, the facility failed to provide supervision to a wandering resident with a known mental health history and previous elopement, conduct an assessment and investigation to determine risk of elopement, develop a care plan addressing elopement risk, and ensure the physician was notified of a resident elopement for one of three residents (R1) reviewed for elopement in the sample of three. These failures resulted in R1, a resident with a known history of multiple psychiatric issues, eloping from the facility at night during freezing temperatures, without staff knowledge, and was later found wandering over a half of a mile from the facility, near a busy highway, with urine saturated pants, confusion, and agitation. These failures resulted in an Immediate Jeopardy. An Immediate Jeopardy situation was identified to have started on 12/27/2024 when R1 eloped from the facility. The facility failed to identify and investigate R1's incident as an elopement and failed 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.
- Actual harm · H2025-05-07 · tag F0627 — patternEnsure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
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 obtain Facility Initiated Discharge Physician Orders, follow current Discharge Care Plans, provide written 30 Day Notice of Discharges to resident's/resident's responsible party, document discharge planning and resident specific needs/services, and document sufficient preparation/orientation to residents to ensure safe/orderly transfers/discharges from the facility for 13 of 14 residents (R1, R2, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13 and R14) reviewed for Facility Initiated Discharges in a sample of 14. These failures resulted in residents suffering psychosocial harm as any reasonable person would experience after being displaced from their home and moved further away from family and friends and R5 verbalizing feelings of anxiety, sadness and anger. Findings include: The Facility Resident Midnight Census Report, dated 4/25/25, documents 23 occupied Resident beds in the Facility. The Facility Resident Room Roster, dated 4/29/25, documents 20…
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 · H2025-05-07 · tag F0628 — patternProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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 record review and interview the Facility failed to notify Resident/Resident's Representatives of transfers/discharges and the reasons for the move in writing at least 30 days prior to transfer discharge, send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman, record the reasons for the transfer/discharge in the Resident's medical record or provide a statement of the resident's appeal rights for 12 of 14 Residents (R2, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13 and R14) reviewed for Facility Initiated Discharges in a sample of 18. These failures resulted in residents suffering psychosocial harm as any reasonable person would experience after being displaced from their home and moved further away from family and friends and R5 verbalizing feelings of anxiety, sadness and anger. Findings include: The Facility Action Summary, dated 4/25/25, documents discharges to area Skilled Nursing Facilities for R6 (3/27/25), R7 (4/18/25), R8 (4/18/25), R9 (4/15/25), 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.
- Actual harm · G2024-07-07 · 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 the physician of a diabetic resident receiving a nutritionally- inadequate clear liquid diet tray for most meals or not eating at all during the span of five days, while continuing to receive the ordered oral and injectable diabetic medications. This failure resulted in R1 being hospitalized for Hypoglycemia and Altered Mental status. FINDINGS INCLUDE: R1's facility Profile Face Sheet documents that R1 was admitted to the facility on [DATE] with the following diagnoses: Diabetes Mellitus, type 2; Morbid Obesity; Vitamin D Deficiency; Anemia; Depression; Mood Disorder, Gastric Esophageal Reflux Disorder and Morbid Obesity. R1's Medication Administration Sheet, dated June 2024 includes the following medications: Jardiance (Sodium- Glucose Co- Transporter 2 Inhibitor) 25 MG (Milligrams) one tablet daily at Noon; Tresiba (Long- Acting Human Insulin) 48 Units subcutaneous daily at Noon; Metformin (Antihyperglycemic) 500 MG one tablet twice daily;…
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 · F2024-09-19 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to have sufficient staff available to provide nursing services to meet the residents' need in the facility. This has the potential to affect all 31 residents currently residing in the facility. Findings include: Facility Assessment Tool, reviewed 1/24/24, documents the following: Staffing plan- facility consults minimum staffing requirements to ensure facility meets the minimum requirements for staffing. Facility considers acuity, daily tasks, and resident needs to ensure staffing meets the needs of the residents. Nurse Aides total number needed (in a 24-hour period) eight. Staff Plan- Direct care staff ratio for days and evenings is three, and direct care staff ratio for nights is two. Facility application for Medicare and Medicaid, dated 9/16/24, documents 31 residents reside in the facility. Staff Daily Assignment postings, dated 8/23/24, 8/26/24, 8/31/24, 9/1/24, and 9/9/24, document for the night shift one CNA/Certified Nurse Aid and one nurse scheduled for the whole eight hours with an average census of 30…
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 · F2024-09-19 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
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 include the Infection Preventionist position or duties in the Facility Assessment. This failure has the potential to affect all 31 residents in the facility. Findings include: Facility application for Medicare and Medicaid, dated 9/16/24, documents 31 residents reside in the facility. Facility assessment dated [DATE] indicates Services provided by the facility include Infection Prevention and Control: Identification and Containment of infections and prevention of infections. Facility Assessment does not include Infection Preventionist position or duties listed under Nursing Services or any other area of the assessment. Infection Preventionist Job Description/Job Summary dated 3/3/23 indicates: The Infection Preventionist is accountable for decreasing the incidence and transmission of infectious diseases between residents, staff, visitors, and community. Through strategic planning, leadership, and consultation, you will lead and direct a robust team in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-09-19 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespreadHave a plan that describes the process for conducting QAPI and QAA activities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to develop, implement, and maintain documentation; and demonstrate evidence of its ongoing QAPI/Quality Assurance Performance Improvement program. This has the potential to affect all 31 residents currently residing in the facility. Findings include: Facility application for Medicare and Medicaid, dated 9/16/24, documents 31 residents reside in the facility. QAPI Plan for (facility), updated 4/1/24, documents The purpose of our Quality Assurance and Performance Improvement Program is to achieve and sustain a culture of excellence by using a fact based, team driven and decision-making model with a proactive approach to continual improvement of the way we care for those we serve. Key monitors are measured and trended on a quarterly basis. The team and committee have the responsibility for planning, designing, implementing and coordinating consumer care and service. The facility was unable to present a QAPI plan to the State Survey Agency no later than one year old. The facility was unable to provide any current documentation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-09-19 · tag F0867 — failed to act on quality-improvement findings — widespreadSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to develop and implement plans of action to make improvements to residents' quality of care and quality of life in its QAPI/Quality Assurance Performance Improvement program. This has the potential to affect all 31 residents currently residing in the facility. Findings include: Facility application for Medicare and Medicaid, dated 9/16/24, documents 31 residents reside in the facility. QAPI Plan for (facility), updated 4/1/24, documents The purpose of our Quality Assurance and Performance Improvement Program is to achieve and sustain a culture of excellence by using a fact based, team driven and decision-making model with a proactive approach to continual improvement of the way we care for those we serve. The QAPI Committee analyzes performance to identify and follow up on areas of opportunity. Identifies opportunities for improvement and uses criteria to prioritize opportunities. The team and committee have the responsibility for planning, designing, implementing, and coordinating consumer care and service. Facility will…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-09-19 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to implement an ongoing infection prevention and control program (IPCP), failed to include an ongoing system of surveillance, and failed to implement a program to manage and minimize the risk of waterborne pathogens. This failure has the potential to affect all 31 residents. Findings include: Facility application for Medicare and Medicaid, dated 9/16/24, documents 31 residents reside in the facility. Facility Policy/Infection Control: Surveillance and Monitoring dated 5/2007 documents: It is the policy of the facility to do routine surveillance and monitoring of the facility to determine if compliance with work practices and care of protective clothing and equipment is maintained. No surveillance monitoring or tracking was found or presented for staff or resident illness. No antibiotic tracking, infection tracking/surveillance was found or presented for April, May, June, or July 2024. On 9/17/24 at 8:30am V1, Administrator stated We have no designated IP (Infection Preventionist) staff at the facility right now. The previous…
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 · F2024-09-19 · tag F0881 — failed to use antibiotics responsibly — widespreadImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to develop and implement an ongoing facility-wide system to monitor the use of antibiotics and failed to include leadership support and accountability via the participation of an individual with designated responsibility for the infection control program (i.e., Infection Preventionist). These failures have the potential to affect all 31 residents in the facility. Findings include: Facility Policy/Assessment of Infections and Antimicrobial Usage dated 1/1/19 documents: Assessing antimicrobial use is essential for determining antimicrobial use trends. Antimicrobial use should be reviewed regularly to measure progress of antimicrobial stewardship activities. Additionally, the results are useful to identify gaps in communication, inconsistencies in documentation, and compliance with facility policies and evidence-based recommendations for antimicrobial prescribing. Align antimicrobial prescribing data and clinical documentation with published recommendations and facility policies. For each prescribed antimicrobial, determine…
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 · F2024-09-19 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
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 employ a Certified Infection Preventionist. This failure has the potential to affect all 31 residents in the facility. Findings include: Infection Preventionist Job Description dated 3/3/23 documents: Qualifications: Must have completed Specialty Training in Infection Prevention and Control through accredited continuing education such as: CDC (Centers for Disease Control) or APIC (Association for Infection Prevention and Control) Infection Preventionist. Facility application for Medicare and Medicaid, dated 9/16/24, documents 31 residents reside in the facility. On 9/17/24 at 8:30am V1, Administrator stated We have no designated IP (Infection Preventionist) staff at the facility right now. The previous IP quit before I started. Our DON (Director of Nursing) does not have an IP certificate or training. The Regional IP nurse does not oversee this building, so we have no one at this time. On 9/18/24 at 3:24pm V1, Administrator stated the previous IP's last day employed at the facility was 9/27/23. V1 stated 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 · F2024-09-19 · tag F0883 — failed to offer flu and pneumonia vaccines — widespreadDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 documentation in the resident's medical record of the administration or refusal of the Influenza and/or Pneumococcal vaccinations for three residents (R17, R26, R29) of five residents reviewed for Influenza and Pneumonia vaccinations in the sample of 21. The facility also failed to provide surveillance monitoring and tracking of immunizations for residents. This failure has the potential to affect all 31 residents. Findings include: Facility Policy/Immunization of Residents dated 1/23/20 documents: Review the residents Immunization Record, Physician order Sheet and Consent Form to verify timing of previous vaccinations, allergies, and contraindications. Document immunization on the resident's Medication Administration Record (MAR) and on the resident's Immunization Record. Facility application for Medicare and Medicaid, dated 9/16/24, documents 31 residents reside in the facility. R17's Influenza and Pneumonia Consent (undated) indicates R17 last received the Influenza vaccine 9/23/22. No documentation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-09-19 · tag F0945 — failed to train staff on abuse prevention — widespreadInclude as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to provide a surveillance system to identify possible communicable disease or infections, how and when to use Transmission Based Precautions and proper infection and prevention and control practices when performing resident care activities. This failure has the potential to affect all 31 residents. Findings include: Facility application for Medicare and Medicaid, dated 9/16/24, documents 31 residents reside in the facility. Facility Policy/Infection Control Surveillance and Monitoring dated 5/2007 documents: Monitoring the effectiveness of the facility work practices and protective equipment will be conducted by the Administrator and DON (Director of Nursing). This includes but is not limited to: Surveillance of the facility to ensure required work practices are observed and that protective clothing and equipment are provided and properly used. Improvement in training, work practices, or protective equipment to prevent reoccurrence. Infection Preventionist Job Description dated 3/3/23 documents: Job Summary: The Infection…
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 · D2024-09-19 · 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 — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to provide a copy of the bed hold policy for the resident discharging to the hospital for one of one resident (R6) reviewed for bed hold in a sample of 21. Findings Include: The facility policy named, Bed Hold Guarantee Policy, dated 8/1/2017, documents the following. The resident, resident family or legal representative will be given the appropriate Notice of Bed Hold Policy at the time of discharge or therapeutic leave, if possible, but notice will be given no longer than 24 hours after discharge or initiation of leave. R6's Short Transfer Form from a local hospital, dated 9/6/2024, documents R6 was seen in the emergency room for a diagnosis of End of Life care. R6's medical record, dated 9/6/2024, lacks the documentation to support that R6 or V6/R6's representative was given a written notice of the bed hold policy prior to discharge. On 9/19/2024 at 10:00 AM, V2/DON (Director of Nurses) stated, No (R6 or V6/R6's representative) did not get a copy of the bed hold policy prior to leaving the facility.
Show the remaining 13 citations
- Potential for harm · D2024-09-19 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to obtain a new level one PASRR (Pre-admission Screening and Resident Review) for 2 of 3 residents (R13 and R25) reviewed for pre-admission screenings in the sample of 21. Findings Include: The facility policy named, Resident Assessment- Coordination with PASRR Program, no date, documents, If a resident who stays in the facility longer than 30days: a. The facility must screen the individual using the State's Level I screening process and refer any resident who has or may have a mental illness or intellectual disability to the appropriate state designated authority. The Social Service Director shall be responsible for keeping track of each resident's PASRR screening status and referring to the appropriate authority. 1. R25's Interagency Certification of Screening Results, dated 10/29/2020, documents the following: Date of admission to facility: 10/28/2020. Screening has indicated a nursing facility is appropriate. R25's Interagency Certification of Screening also documents that R25's screening is valid for only 90 days 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.
- Potential for harm · D2024-09-19 · 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 notify the physician and initiate treatment for a skin fold wound for one resident (R20) of one resident reviewed for skin impairments in the sample of 21. Findings include: Facility Policy/Skin Condition Monitoring dated 1/18 documents: It is the policy of this facility to provide proper monitoring, treatment, and documentation of any resident with skin abnormalities. Upon notification of a skin lesion, wound, or other skin abnormality, the Nurse will assess and document the findings in the nurses notes and complete QA (Quality Assurance) form for Newly Acquired Skin Condition. The Nurse will then implement the following procedure: Notify the physician and obtain treatment order. The treatment order will include: Type of Treatment Location of area to be treated Frequency of how often treatment is to be performed How area is to be cleaned Stop date - if needed Any skin abnormality will have a specific treatment order until area is resolved. PRN (as needed) orders should not be obtained for a skin abnormality.…
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 · D2024-09-19 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to maintain and process pharmacist drug regimen review recommendations for one (R24) of 12 residents reviewed for drug regimen review in a sample of 21. Findings include: R24's Medication Regimen Review/MRR for July and September 2024 documents See report for any noted irregularities and/or recommendations. R24's medical record had no documentation, and the facility was unable to provide MRRs for July and September 2024 prior to the survey exit. On 9/19/24 at 12:48 PM, V2 DON/Director of Nursing stated I cannot find (R24's) MRR for July and September 2024. We keep them in the residents' medical record, but I don't know where (R24's) are.
- Potential for harm · D2024-07-07 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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 allow a resident the right to exercise the choice to eat meals in bed, for two of three residents (R1, R2), reviewed for resident rights, in a sample of three. FINDINGS INCLUDE: R1's facility Profile Face Sheet documents that R1 was admitted to the facility on [DATE] with the following diagnoses: Diabetes Mellitus, type 2; Morbid Obesity; Vitamin D Deficiency; Anemia; Depression; Mood Disorder, Gastric Esophageal Reflux Disorder and Morbid Obesity. R1's current Minimum Data Set Assessment, dated 4/20/24 documents, Section C0500: BIMS (Brief Interview for Mental Status) as 15:15 (Cognitively Intact). This same form documents, Section GG0130: Eating-Set up or clean up assistance: Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. R1's current Care Plan, dated 7/18/23 documents, (R1) has a long history of obesity. (R1) consumes more than 75% of meals. (R1) is able to feed himself…
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 · D2024-07-07 · tag F0800 — isolatedProvide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a resident with a nourishing, well balanced diet for one of three residents (R1), reviewed for nutrition, in a sample of three. FINDINGS INCLUDE: R1's current Physician Order Sheet, dated June 2024 documents that R1 was admitted to the facility on [DATE] with the following diagnoses: Diabetes Mellitus, type 2; Morbid Obesity; Vitamin D Deficiency; Anemia; Depression; Mood Disorder, Gastric Esophageal Reflux Disorder and Morbid Obesity. This same document includes the following diet order: CCD (Carbohydrate Controlled Diet), Regular. On 7/5/24 at 8:35 a.m., V1/Administrator stated, (R1) has been getting a sick tray for some time now. (R1) refuses to get up for supper. I myself have taken (R1) his sick tray, many times. On 7/5/24 at 2:09 P.M., V5/Registered Nurse stated, (R1) had been sick for about a week with a head cold. (R1) wasn't eating much. (R1) requested to eat in bed. (R1) wanted his regular tray, but (R1) can only have it, if (R1) 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.
- Potential for harm · D2023-08-10 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 develop resident care plans for three (R1, R14, and R17) of 12 residents reviewed for care planning in a total sample of 19. FINDINGS INCLUDE: The facility's Comprehensive Care Planning, policy, and procedure, revised 7/20/22, documents, It is the policy of (the facility) to comprehensively assess and periodically reassess each Resident admitted to this facility. The results of this Resident assessment shall serve as the basis for determining each Resident's strengths, needs, goals, life history and preferences to develop a person-centered comprehensive plan of care for each Resident that will describe the services that are to be furnished to attain or maintaining the Resident's highest practicable physical, mental, and psychosocial well-being. It is to be noted that the Care Plan is for planning care and services. Comprehensive Care Plans shall strive to describe a. The resident's preferences, choices, and goals to the extent possible to assist in attaining or maintaining the resident's highest practicable…
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 · F2022-07-28 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to provide the services of a Registered Nurse eight hours a day, seven days a week. This failure has the potential to affect all 29 residents residing in the facility. Findings include: The facility's Nursing schedule dated 7/17/22-7/30/22 documents on 7/23/22 and 7/24/22 the facility had no scheduled Registered nurse hours. The facility's Nursing Attendance reports, dated 7/23/22 and 7/24/22, do not document that the facility provided eight consecutive hours of a Registered Nurse on any shift for both dates. On 7/27/22 at 10:45 AM, V1 (Administrator) confirmed she did not have any Registered Nursing hours for the past weekend (7/23/22- 7/24/22). V1 stated This has been an issue all the time. Getting weekend Registered Nurse coverage is always a struggle and I don't know why. The facility's Resident Census and Conditions of Residents (Centers for Medicare and Medicaid-672) form, dated 7/25/22 and signed by V1, documents the facility has 29 residents residing in the facility.
- Potential for harm · F2022-07-28 · tag F0886 — failed to test for COVID-19 as required — widespreadPerform COVID19 testing on residents and staff.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to perform the required twice weekly COVID-19 testing on staff members who are currently not up to date with the COVID-19 vaccination. This failure has the potential to affect all 29 residents residing in the facility. Findings include: The facility's COVID Testing Plan (undated) documents the following: For non-boosted, unvaccinated or not up to date staff: COVID testing is every Tuesday and every Thursday. On 7/27/22 at 11:30 AM, V1/Administrator stated the facility currently has two employees (V8, Registered Nurse and V9, Certified Nursing Assistant) with exemptions in place for the COVID-19 vaccination, and 14 employees who are not currently up to date with their COVID-19 vaccination status (V10, V16, V18 and V19 Licensed Practical Nurses; V5, V11-V14, V17 Certified Nursing Assistants; V15 Regional Director; V20 and V21, Laundry; and V22, Regional Reimbursement Specialist). V1 stated the above employees are required to be tested for COVID-19 twice a week. On 07/27/22 at 12:00 PM, V1/Administrator provided the facility's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2022-07-28 · tag F0888 — widespreadEnsure staff are vaccinated for COVID-19
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 all staff members were fully vaccinated for COVID-19. This failure has the potential to affect all 29 residents residing in the facility. Findings include: The facility's COVID-19 Vaccine Policy and Procedure (revised 2/24/22) documents the following: Purpose: To establish a process to comply with the Federal Mandate that all staff are vaccinated against COVID-19 unless they have a medical or religious exemption to help reduce the risk residents and staff have of contracting and spreading COVID-19. On 7/27/22 at 11:30 AM, V1 (Administrator) provided the facility's Employee COVID Vaccination Log, which includes record of all facility staff members' COVID-19 vaccinations and booster doses that have been administered. This log documents the following staff members were not up to date on their COVID-19 vaccination status: V10, V16, V18 and V19 Licensed Practical Nurses; V5, V11-V14, V17 Certified Nursing Assistants; V15 Regional Director; V20 and V21, Laundry; and V22, Regional Reimbursement Specialist. On 07/27/22 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-07-28 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to place a resident in the required transmission-based precautions. This failure has the potential to affect four of four residents (R13, R25, R128 and R129), reviewed for infection control in a sample of 19. The facility policy, Multi-Drug-Resistant Organisms in Non-Hospital Healthcare Setting, dated (reviewed 4/11/22) directs staff, multi-resistant drug organisms are bacteria and other microorganisms that have developed resistance to antimicrobial drugs. Common examples of these organisms include: ESBL (Extended Spectrum Beta Lactamase). Risk factors for development (of ESBL) include underlying diseases or conditions, particularly Chronic Renal Disease. In addition to Standard and Contact Precautions, place the resident in a private room. R128's Physician Order Sheet, dated July 2022 documents that R128 was admitted to the facility on [DATE] with the following diagnosis: Chronic Kidney Disease. This same form includes the following…
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 · D2022-07-28 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure policies and procedures regarding hand hygiene were followed during pressure ulcer care for one of one residents (R21) reviewed for pressure wounds, in a sample of 19. FINDINGS INCLUDE: The facility policy, Pressure Ulcer Dressing Change, dated (revised 07/07) directs staff, To avoid introducing organisms into a wound. Procedure: Gather needed equipment. Position resident comfortably and expose area to be dressed. Set up clean area for supplies. Wash your hands. Apply non-sterile gloves. Remove old dressing and place in a plastic bag. Remove and discard soiled gloves. Wash your hands. Open dressing packages. Put on non-sterile gloves. Cleanse wound per Physician's orders. Apply dressing without touching wound. Secure dressing. Remove gloves. Wash your hands. R21's current Physician Order Sheet, dated July 2022 documents that R21 was admitted to the facility on [DATE]. This same form includes the following Physician orders: Coccyx,…
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 · D2022-07-28 · 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
Based on observation, interview and record review, the facility failed to reconcile controlled medications for one of 13 residents (R21) reviewed for medications in the sample of 19. FINDINGS INCLUDE: The facility policy, Controlled Substances, dated (revised) 11/6/18 directs staff, It is the policy of the facility that all drugs listed as Schedule II drugs are subject to specified handling, storage, disposal and record keeping. Schedule II drugs are to be kept under two separate locks requiring two separate keys. A permanently affixed locked cabinet within the locked medication cart may be used for safe keeping. The Schedule II cabinet must remain locked, and the Charge Nurse shall have the key in her possession at all times. Only Licensed Nurses will have access to Controlled Substances. A control sheet for each prescription will be initiated. The control sheet will contain: Resident's Name, ordering Physician name, Issuing Pharmacy, Name and strength of drug, Quantity received, and date and time received. The drugs in Schedule II (and those in other schedules which have been…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2024-09-19 · tag F0623 — widespreadProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to provide a resident and resident's representative with a written notice of transfer (R6) and the facility failed to notify the facility Ombudsman monthly of resident transfers to the hospital. This failure has the potential to affect all 31 residents residing in the facility. Findings include: 1. R6's Nurses Notes, dated 9/6/2024, documents the following: At 3:45 PM, R6 is violently tremoring. Hospice is requesting a hold of medications for comfort as Hospice believes R6 is over medicated. V6/R6's POA/Power of Attorney notified and requests that R6 be sent out to the emergency room to be evaluated. Request granted. R6 was sent to the emergency room to be evaluated. R6's chart lacks the documentation to show that R6 and V6/R6's POA was notified in writing of the transfer/discharge to the emergency room. On 9/19/2024 at 10:00 AM, V2/DON (Director of Nurses) stated, I cannot find anywhere that a written notice of transfer was given to (R6 or V6/R6's POA (Power of Attorney). I know that V6 requested a transfer, but I cannot be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | 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 14E361. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-09-19, 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.