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Avenues At Springfield

525 So Martin Luther King Dr, Springfield, IL 62703 · For profit - Limited Liability company · 65 certified beds · (217) 789-1680 Medicaid only — no Medicare

Call the home — (217) 789-1680 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0610) — cited Jan 2024Behavioral-health or dementia-care citation at the harm level (F0740)2 actual-harm citations1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (59%) runs well above the national median (45%)

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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
5850 South 6th Street, Suite A
Pharmacy
Cub Foods1.1 mi
2777 S 6th St · (217) 744-2296 · Call to confirm hours
Grocery
2023 S 15th St · (217) 679-3762 · Call to confirm hours
Park
1628 E Stanford Ave · (217) 544-1751 · Typically dawn to dusk
Place of worship
2517 S 14th St · (217) 971-8544

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 4 of 5
Long-stay residentspeople who live here 4 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 1 to 2 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.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased7.8%13.4%15.4%better
Long-stay residents who lose too much weight15.1%6.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.9%0.9%better
Long-stay residents with a urinary tract infection0.4%1.5%2.0%better
Long-stay residents with depressive symptoms94.4%54.2%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.7%3.1%3.3%better
Long-stay residents whose ability to walk worsened2.2%14.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication42.2%18.3%18.9%worse
Long-stay residents given the seasonal flu vaccine93.8%91.8%95.3%typical
Long-stay residents with pressure ulcers0.0%4.8%4.7%check this — see note marked star below the table
Long-stay residents with worsening bladder/bowel control13.8%20.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table54.9%21.7%17.1%check this — see note marked dagger below the table
Long-stay hospitalizations per 1,000 resident days2.682.021.67worse
Long-stay outpatient ER visits per 1,000 resident days3.052.221.80worse

* 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.

This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. 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

0.23
RN hours/ resident / day
0.42
LPN hours/ resident / day
0.94
Aide hours/ resident / day
1.58
Total nurse hours/ resident / day
0.15
RN hoursweekends
59.3%
Total nursing turnover
80.0%
RN turnover

How full it usually is: this home is certified for 65 beds and averages 63.5 residents a day — about 98% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. 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 1.58 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.23 is below the 0.55-hour RN benchmark and nurse-aide staffing of 0.94 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 1.38 hrs/resident/day on weekends vs 1.66 on weekdays — 17% thinner on weekends. RN hours go from 0.26 to 0.15 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 59% is well above the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

4
deficiencies at the latest standard inspection (2026-01-29)
4
at the previous standard inspection (2024-08-01)

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.

ABCDEFGHIJKL

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.

25 citations, most serious first. The 13 most serious are shown; the remaining 12 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-01-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent an elopement in 1 of 4 residents (R2) reviewed for elopement/supervision in the sample of 4. This failure resulted in an Immediate Jeopardy when R2 eloped from the facility on 12/30/24 and while missing, R2 sustained a fall resulting in a laceration and nasal fracture. This past non-compliance occurred on 12/30/24. Past noncompliance-no plan of correction required. The Immediate Jeopardy began on 12/30/24, when R2 eloped from the facility and sustained a fall resulting in a laceration and nasal fracture. On 1/15/25, at 9:30 AM, V1, Administrator, and V2, Director of Nurse, DON, were notified of the Immediate Jeopardy. The surveyor confirmed by observation, interview and record review, the Immediate Jeopardy was removed, and the deficient practice was corrected on 12/30/24, prior to the start of the survey and was therefore Past Noncompliance. Findings include: On 1/14/25 at 8:50 AM, V1, Administrator, stated R2 recently eloped from the…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Actual harm · G2023-06-15 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to report a resident's significant weight loss to the physician and initiate appropriate interventions to maintain and/or improve nutritional status for 1 of 4 residents (R29) reviewed for weight loss in the sample of 65. The failure resulted in R29 having an insidious weight loss of 14.5 pounds (lbs.), a 10% weight loss in the last six months. Findings include: On 6/11/23 at 12:15 PM R29 was standing at the entrance to the dining room. He had not eaten any lunch or drank any of his fluids. He walked to the dining room and then turned around and went right back down to his room. He stated he was not going to eat lunch. His pants were so loose that he had to hold them up at the waist while he was walking. V7, Certified Nursing Assistant (CNA) stated, He just doesn't feel good today. V7 did not encourage R29 to go back to the dining room to eat and did not offer him any substitutes or alternatives. R29 returned to his room and laid on his bed.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2023-06-15 · tag F0740 — failed to provide behavioral / mental-health care — isolated
    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to assess, develop, and implement interventions to address the worsening symptoms of mental illness disorders for 1 of 5 residents (R29) reviewed for behavioral health services in the sample of 65. This resulted in R29 having a significant weight loss due to worsening and ongoing hallucinations telling him not to eat or drink. Findings include: R29's Face Sheet documents his diagnoses to include Schizophrenia, Major Depressive Disorder, Vitamin B Deficiency, Bipolar Disorder, Avoidant Personality Disorder, Panic Disorder and Anxiety Disorder. R29's Minimum Data Set (MDS) dated [DATE] documents he is alert and oriented and able to feed self independently with supervision and set up assist by staff. On 6/11/23 at 12:15 PM R29 was standing at the entrance to the dining room. He had not eaten any lunch or drank any of his fluids. He walked to the dining room and then turned around and went right back down to his room. He stated he was not going…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2026-01-29 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to perform hand hygiene and glove changes appropriately and failed to label, date and cover food in the kitchen refrigerator. The failure could affect all 64 residents who live in the facility.Findings include:1.On 01/27/2026 at 9:30 AM in refrigerator #1, there was a gallon of 2% milk, opened and had an expiration date of 1/25/26. In refrigerator #2 there was a 1/2 pound of butter opened, not labeled or dated. In the freezer there was a sandwich bag of green beans that was not labeled nor was it dated. There was also a bag of frozen fritters that was not labeled nor dated. V13, Dietary Manager was made aware of the items that were not labeled or dated.2. On 1/27/2026 at 10:00 am, V14, Dietary aide, did not have a hair net on while wrapping silverware. When he was asked about it, he stated that he should have a hair net on, but it fell off into the hood part of his sweatshirt. V14 then placed it back on his head without benefit of hand hygiene, he began wrapping silverware again. On 1/27/2026 at 10:05 AM, V13,…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-01-29 · tag F0880 — failed to prevent and control infections — widespread
    Provide 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 implement and maintain effective measures to prevent the growth and transmission of Legionella bacteria within the water system. This has the potential to affect all 64 residents residing at the facility. Findings include: 1. On 1/28/2026 at 12:12PM V6, maintenance interviewed regarding water management and prevention of legionella. V6 stated the facility calls a contractor for the prevention of legionella. V6 stated the contractor checks for algae. V6 stated he would have to check his book to see if there were any legionella in past year. V6 was unable to describe water flow and stated he would have to check his book for diagram of water flow. V6 stated he did not know the answer if the facility had empty resident rooms in regard to the prevention of legionella. On 1/29/2026 at 10:29AM V1, Administrator stated she would expect the facility to follow the water management program for the prevention and growth of legionella. V1, stated V6,…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-01-29 · tag F0882 — widespread
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, interview and record review the facility failed to provide a trained infection preventionist at the facility. This has the potential to affect all 64 residents at the facility.Findings include:On 01/28/2026 at 11:00 AM V1 administrator stated V2, Director of Nursing (DON) is infection preventionist. V1 stated V2 does not have a certificate and is working under V10, regional nurse. V1 stated V2, DON started on Monday, Jan. 19th 2026. On 1/28/2026 at 11:50AM V2, DON stated she does not have a certificate and is working under the regional nurse, V2, DON stated she signed up for the infection prevention course yesterday and will be taking the course this weekend.On 1/29/2026 at 10:29AM V1, Administrator stated she would expect a trained infection preventionist to be onsite at the facility. V1 did state the regional nurse does not work at the facility. On 1/29/2026 at 10:29AM V1, administrator stated the facility does not have a specific policy for infection preventionist but does follow state guidelines. The CMS 671 dated 1/27/2026 documents a census of 64.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2026-01-29 · tag F0912 — widespread
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the Facility failed to provide 80 square feet of floor space per resident bed for 32 two-bed resident rooms residents. This has the potential to affect all 64 residents in the facility.Finding includes:The facility has 32 two-bed resident rooms that can be occupied by 2 residents. According to historical data, the room measurements for these rooms provide only 76 square feet per bed. All these rooms are certified for Medicaid. These rooms are as follows:The following residents reside in A1 through A16: R48, R23, R59, R35, R36, R19, R42, R33, R1, R50, R27, R64, R55, R34, R8, R25, R5, R63, R41, R47, R44, R18, R30, R17, R52, R39, R46, R28, R38, R57, R7, and R16.The following residents reside in B1 through B16: R4, R15, R11, R3, R61, R21, R2, R32, R20, R31, R54, R49, R26, R14, R51, R6, R43, R37, R60, R62, R13, R9, R58, R56, R22, R24, R10, R29, R40, R45, R12, and R53.On 1/29/26 at 1:01 PM, V12 ADON (assistant director of nursing) stated all rooms in the facility are being occupied.On 1/27/26 at 9:26 AM, V1 (administrator) stated all 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-04-08 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews and record reviews the facility failed to ensure there was an air gap in the ice machine between the ice storage bin and floor sewage drain in ice machine and staff had warm water to wash their hands. This has the potential to affect the 61 residents living in this facility. Findings include: On 4/1/2025 at 9:32 AM, the metal thermometer was calibrated. On 4/1/2025 at 9:38 AM, the kitchen staff washing sink station water temperature was taken after running for one minute and the temperature was 69.5 Fahrenheit (F). On 04/01 /2025 at 9:42 AM, the ice machine was observed in sprinkler/employee break room. There was a hose that extended from the back through the wall to underneath leading to the outside. The hose to the ice storage bin of the ice machine was submersed into to pipe with no visible gap between the end of the hose and the drain to ensure that no sewage could back up into the ice machine. On 4/1/2025 at 9:49 AM, V1, Administrator stated, I am not sure what you are referring to regarding an air gap. Our machine has always been like that 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-04-08 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the plumbing system provided comfortable hot water temperatures for resident use for 10 of 15 residents (R1, R2, R3, R8, R9, R10, R11, R12, R14 and R15) reviewed for safe in the sample of 15. Findings include: On 4/1/2025 at 9:28 AM, water temperatures were taken with a metal calibrated thermometer. On 4/1/2025 at 9:32 AM, R2 stated water is always cold, she shares a sink in bathroom and shower room. The water is cold at her sink and in the shower room. R1, R2 and R3 all share a bathroom sink. On 4/1/2025 at 9:33 AM, V1, Administrator stated she was not aware of any issues with water temperatures. On 04/01 /2025 at 9:47 AM, R8 stated, The water was cold today. The showers are cold too. I tried to wash my hair, but it was too cold today to wash my hair, I just can't do it. R8 shares a room with R9. R9 was not interviewable. On 4/1/2025 at 9:57 AM, R8 and R9's sink registered 69.5 degrees Fahrenheit (F). This sink is shared with R8, R9, R10 and R11. On 4/1/2025 at 10:04 AM, R14 stated the water was cold…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-08-01 · tag F0727 — failed to provide required RN coverage — widespread
    Have 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, observation, and record review, the facility failed to provide 8 consecutive hours of Registered Nurse Coverage. This has the potential to affect all 61 residents residing in the facility. Findings include: On 7/30/2024, V2, Director of Nurses (DON), stated that the facility does have days that the facility is unable to staff 8 consecutive hours of Registered Nurse coverage. V2 stated she has been trying to hire Registered Nurses but hasn't had any applicants lately. On 7/31/24 at 8:30 AM, V2, stated the facility does not have a policy on 8 hours of consecutive Registered Nurse hours but she tries to meet the regulation. On 7/30/24, V2 was the only Registered Nurse in the building. The Nursing Unit Postings from 6/1/2024 - 7/29/2024 were reviewed. The facility failed to have 8 hours of consecutive Registered Nurses coverage on: 6/3/24, 6/8/24, 6/9/24, 6/17/24, 6/28/24, 7/2/24, 7/6/24, 7/7/24, 7/20/24, and 7/29/24. The Long-Term Care Application for Medicare and Medicaid dated 7/29/24, documents 61 residents reside in the facility.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-08-01 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, observation, and record review, the facility failed to wear hair nets covering the hair, store food at a safe temperature, document food temperature after taking them, and have clean and sanitary equipment to prevent potential food contamination and food-borne illness. This failure has the potential to affect all 61 residents residing in the facility. Findings include: 1.On 7/29/24 from 12:05 PM until 12:26 PM, V9, Preparation Cook, was observed without out a hair net covering her hair. V9 is assisting V8, Cook, placing uncovered food items onto the resident's tray and then placing the tray onto the service counter for staff to deliver to the residents in the dining room. V9 has past the shoulder braided hair that is pulled into a ponytail. V9 's hair net is at the end and side of the ponytail caught in the hair but not covering any hair. 2.On 7/31/24 at 11:44 AM the kitchen was entered. The thermometer was calibrated and shown to V7, cook. The noon meal food items were corn dogs, stewed tomatoes, cold macaroni salad and peach cake. The macaroni salad was 60.2…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-01 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record review the facility failed to provide services to residents with gastrostomy tube to restore/maintain eating skills for one of one resident (R40) reviewed for tube feedings in the sample of 65. Findings include: R40's Face Sheet, date 8/1/2024, document diagnoses of Schizophrenia, major depressive disorder, anxiety, Chronic Obstructive Pulmonary Disorder (COPD), Parkinson, benign prostatic hyperplasia, Hypertension, hyperlipidemia, Gastroesophageal reflux disorder, insomnia, and protein calorie malnutrition. R40's clinical record does not document any dysphagia or swallow issues. R40's physician orders dated 4/2024, prior to hospitalization on 4/23/2024 documents R40 was ordered a REGULAR diet, Mechanical Soft, Ground Meat texture, thin consistency on 4/1/2024. R40's Progress Note, dated 4/23/2024 at 7:52pm documented R40 was admitted to local hospital for COPD exacerbation and pneumonia. R40's Facility's progress notes dated 4/24/2024 at 11:32AM documented R40's plan of care. R40's progress note documented R40 is noncompliant and refusing majority 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-04-24 · tag F0725 — failed to have enough nursing staff — widespread
    Provide 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 interviews and record review the facility failed to always maintain a nurse on duty to meet the needs and safety of all residents. This failure has the potential to affect all 62 residents that reside in the facility. On 4/23/2024 at 12:27pm, V5, (Ambulance staff), stated that on 4/19/2024 around 8pm, V5 was returned R2 to the facility via ambulance transfer. V5 stated, there was no Nurse on duty in the building when they arrived to receive R2 back into the facility for care. V5 stated, V4, (Certified Nursing Assistant, CNA), told her that V3 had left and would be back shortly. V5, (Ambulance staff), stated 15-minutes passed with no signs or return to the facility of V3, (LPN). On 4/23/2024 at 2:30pm, V4, (CNA), stated, that on 4/19/2024 around 8pm, R2 returned from the hospital via Ambulance and V3, (LPN), was not in the facility. V4 stated, she called V3, and V3 will be back shortly. V4 stated, the Ambulance waited for a few minutes and then made a phone call, then left R2 at the facility with V4. On 4/23/2024 at 3:00pm, V3, (LPN), stated, that on 4/19/2024, she left 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · Fcited before2024-04-24 · tag F0727 — failed to provide required RN coverage — widespread
    Have 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 record review and interviews the facility failed to provide the services of a Registered Nurse for 8 consecutive hours on the dates of 04/01/2024, 04/06/2024, 04/15/2024, 04/18/2024, 04/19/2024 and 04/20/2024. This failure has the potential to affect all 62 residents that reside in the facility. On 04/23/2024 at 1:00pm, V1 (Administrator) stated there are some days that the facility does not have a Registered Nurse for 8 consecutive hours a day. V1 stated current census is 62 and noted by the Matrix obtained from V1. On 04/23/2024 at 1:30pm, Facility provided the Nursing schedules with no RN scheduled to work on the following dates 04/01/2024, 04/06/2024, 04/15/2024, 04/18/2024, 04/19/2024 and 04/20/2024. On 04/23/2024 at 2:30pm, V4 (Certified Nursing Assistant) stated there are some days that there is no RN working in 24-hours. On 04/24/2024 at 8:30am, V1 stated the facility does not have a staffing policy but the facility is supposed to follow the Regulations for staffing.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-31 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to document narcotic pain medication administration for 4 of 4 (R1, R2, R3 and R4) residents reviewed for medication administration, in a sample of 4. Findings include: 1. R1's Physician Order sheets, dated 1/2024, documented, an order for Hydrocodone-Acetaminophen (APAP) Oral Tablet 5-325 MG 1 tablet by mouth every 6 hours as needed for pain. R1's Narcotic count sheet, dated 1/14/2024 to 1/28/2024, documented, Hydrocodone-Acetaminophen Oral Tablet 5-325 MG 1 tablet by mouth every 6 hours as needed for pain contained 25 entries. R1's Medication administration record, dated, 1/14/2024 to 1/28/2024, documented 5 entries of Hydrocodone-Acetaminophen Oral Tablet 5-325 MG 1 tablet by mouth every 6 hours as needed for pain. R1's Minimum Data Set (MDS), dated [DATE], documented that her cognition was intact. On 1/29/2024 at 1:30pm, R1 stated that she receives her pain when she needs them including on second and night shift. 2. R2's Physicians order sheet, dated…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-31 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond 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 record review and interview the facility failed to thoroughly investigate an allegation of misappropriation of narcotic pain meds, for 1 of 3 (R2) residents, reviewed for abuse, in a sample of 4. Findings include: R2's Minimum Data Set, dated [DATE], documented his cognition was moderately impaired. On 1/29/2024 at 2:00 pm, R2 stated he told the staff he wasn't getting his pain meds and he was told by them he has to ask for it. R2 stated he originally was getting his pain meds three times a day but now he only gets it when he asks for it. R2 stated the head nurse told him he had to ask for it or he won't get it. R2 stated, I am confused but if I ask for my pain medication, I do get it. On 1/29/2023 at 9:45am, V1, Administrator, stated V3, Nurse Consultant, received a compliance line call from R2's ex-wife stating R2 was not receiving his narcotic pain medication and R2 believes someone is taking his medications. V1 stated this was investigated and the Director of Nurses conducted an audit of R2'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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-02 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews the facility failed to provide a safe environment by having toilets that were not securely bolted to the floor for 8 of 20 residents (R4, R5, R7, R8, R9, R10, R11 and R12) and failed to have toilet in hallway A shower room securely bolted to floor with the potential to affect 23 of 24 residents. Findings include: On 9/27/2023 at 1:15pm V1, (Administrator), stated she was not aware of toilets not being bolted securely to the floor. On 9/27/2023 at 1:00pm observations of R7's toilet not secured to floor. R7's toilet had rusted bolts that no longer held toilet securely to floor. On 9/27/2023 at 1:10pm observations of shower room on B hallway with toilet not secured to floor. Toilet had rusted bolts that no longer held toilet securely to floor. On 9/27/2023 at 3:00pm observations of room A8's toilet not secured to floor. A8's toilet had rusted bolts that no longer held toilet securely to floor. R8 and R9 reside in this room. On 9/27/2023 at 3:12pm observations of R5's toilet not secured to floor. R5's toilet had rusted bolts that no longer held…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-08-14 · tag F0711 — pattern
    Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
    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 continuity of care and documentation of Physician's Assessments in the Electronic Medical Record, (EMR), in a timely fashion for 4 of 4 residents (R1, R4, R10 and R11) reviewed for Physician Services in the sample of 11. The findings include: On 8/8/2023 at 8:45 AM V1 Administrator, stated, (V4, Medical Director, MD) was working for (local hospital) but, now he has his own clinic. He (V4) is a little behind on Progress Notes, but he said he will be in today. On 8/8/2023 at 10:00 AM V1 stated, V4 is the current Medical Director, (MD). V1 stated, V4, MD, does his own Progress Notes after his visits. On 8/8/2023 at 10:43 AM, V1 stated, I was telling (V2, Director of Nurses, DON) I was concerned he (V4) hadn't put notes in the (EMR, electronic medical records). On 8/8/2023 at 11 AM, V2 stated, the facility does not have a policy pertaining to Physician's documentation. On 8/8/2023 at 11:57 AM, V4 stated, he used a different charting system up until…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-14 · tag F0712 — isolated
    Ensure that the resident and his/her doctor meet face-to-face at all required visits.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Physician's Assessments were completed upon admission in a timely fashion for 1 of 4 residents (R10) reviewed for Physician's Services in the sample of 11. Findings include: The Facility's admission Report documents, R10 was admitted on [DATE]. On 8/8/2023 at 11:20 AM, V11, Registered Nurse, (RN), stated, V4, Medical Director mentioned to V11 that he doesn't always know when the facility gets a new admission. V11 stated, That's something we need to work on. On 8/8/2023 at 2 PM, V4, Medical Director stated, they (V4 and facility staff) have been working on a new system but stated, he (V4) was not always notified when there was a new admission. On 8/9/2023 R10's EMR does not include an initial H&P or any additional Physician's Progress Notes. On 8/9/2023 at 1:45 PM, V2, Director of Nursing verified there were no Physician's Notes in R10's EMR.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-06-15 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, serve, and sanitize food and dining surfaces in a manner to prevent potential contamination and food borne illness. This failure has the potential to affect all 63 residents living in the facility. Finding include: On 6/11/23 at 8:03 V11, Dietary Aide, and V5, Cook, were in the kitchen finishing up serving the morning meal. V5 was not wearing a beard protector. V5 had a substantial beard. The dry storage room had one large box containing many smaller boxes of Raisin Bran cereal, a case of canned fruit mix, a case of pan liners, a large case of spaghetti sauce, a large box of dried rice and a case of potatoes are on the storage room floor with multiple boxes of food products stacked on top of them. On 6/11/23 at 8:30 AM, V11 was in the dining room clearing off and cleaning the dining room tables. V11 was asked what she was using to sanitize the tables, V11 stated, The sanitizer that I get from the sink. V11 stated, This stuff right here. You just turn it on and fill the bucket. The sanitation solution…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-06-15 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop 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 provide Pneumococcal vaccine for 4 of 4 residents (R4, R5, R35, R64) reviewed for immunizations in the sample of 65. Findings include: 1. R35's admission Sheet, print date of 6/14/23, stated R35 was admitted on [DATE] and his date of birth is 1/31/1954. R35 is [AGE] years old. This admission Sheet documents stated R35 has diagnoses of Anxiety, Dementia, Hypertension and Chronic Obstructive Pulmonary Disease. R35's Minimum Data Set (MDS), dated [DATE], documents stated R35 is cognitively intact. R35's Authorization and Release for Pneumococcal (PCV13&PPSV23), dated 3/1/23, documents stated R35 consented to receiving the PCV13 and the PPSV23 vaccine. There was no documentation in R35's medical record R35 received the PCV13 and the PPSV23 vaccine. 2. R4's admission Sheet, print date of 6/14/23, documents R4 was admitted on [DATE] and her date of birth is 9/29/1945. R4 is [AGE] years old. This admission Sheet documents stated R4 has diagnoses of Acute…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-15 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to promote residents dignity by protecting their right to a sense of well-being and safety for 1 of 1 resident (R37) reviewed for dignity in the sample of 65. Finding include: On 6/12/23 at 10:00 AM, R37 was walking up the hall and stated, I'm tired of them smoking the marijuana in my room. It's not right. When asked who he was talking about he said, (R7) and (R18). I'm tired of it. Can you do something about it? When asked about when this happened, R37 stated, I don't know, maybe a week ago. When asked if he had reported this to anyone who works in the facility. R37 stated, No, I'm reporting this to you. On 6/12/23 at 1:00 PM, R37 stated he talked to V17, Psychosocial Rehab Service Coordinator, about the other residents smoking in his room. On 6/14/23 at 10:40 AM, V26, Housekeeping, called for R7 to come outside for smoke time. V26 opened R7's bedroom door at the same time R7 came out of R37's and R9's room. V26 asked R7 what R7 was doing.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to provide supervision to prevent residents with substance abuse disorders from acquiring and smoking marijuana for one of 14 residents (R7) reviewed for supervision in the sample of 65. Findings include: On 6/12/23 at 10:00 AM, R37 stated, I'm tired of them smoking the marijuana in my room. It's not right. When asked who he was talking about he said R7. R37 stated I'm tired of it. Can you do something about it? When asked about when this happened, R37 stated, I don't know, maybe a week ago. On 6/12/23 at 1:00 PM, R37 stated he talked to V17, Psychosocial Rehab Service Coordinator (PSRC), about the other residents smoking in his room. R7's admission Record Sheet, with print date of 6/14/23, documents R7 has diagnoses that included bipolar disorder, schizophrenia, major depressive disorder. R7's Minimum Data Set (MDS) dated [DATE] documents R7's Brief Interview of Mental Status Score as 15 which indicates R7 is cognitively intact. R7's MDS…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · Ccited before2024-08-01 · tag F0912 — widespread
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the Facility failed to provide 80 square feet of floor space per resident bed for 32 two-bed resident rooms residents. This has the potential to affect all 61 residents in the facility. Finding includes: The facility has 32 two-bed resident rooms that can be occupied by 2 residents. According to historical data, the room measurements for these rooms provide only 76 square feet per bed. All these rooms are certified for Medicaid. These rooms are as follows: The following residents reside in A1 through A16: R115, R 24, R5, R46, R10, R32, R44, R62, R19, R60, R12, R25, R43, R42, R51, R16, R50, R34, R31, R9, R36, R13, R23, R27, R61, R49, R29, R21, R59, R14, R5 and, R11. The following residents reside in B1 through B16: R40, R6, R38, R22, R52, R3, R30, R37, R54, R39, R47, R33, R45, R8, R17, R48, R41, R35, R57, R15, R7, R28, R1, R58, R4, R20, R26, R18, R2 and R56. On 7/31/2024 at 3:05 PM, V1, Administrator, stated, None of our rooms meet the square footage requirement. We have one private room which is unoccupied at this time. 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · Ccited before2023-06-15 · tag F0912 — widespread
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide 80 square feet of floor space per resident bed for 32 two bed resident rooms for 63 of 63 residents. This failure affects all 63 residents residing in the facility. Finding includes: The facility has 32 two bed resident rooms that can be occupied by 2 residents. According to historical data, the room measurements for these rooms provide only 76 square feet per bed. All these rooms are certified for Medicaid. These rooms are as follows: During this survey, the following residents reside in A1 through A16: R5, R7, R9, R10, R11, R12, R13, R17, R18, R19, R24, R25, R26, R28, R29, R30, R32, R35, R36, R37, R38, R40, R46, R48, R50, R51, R52, R54, R56, R57, R61. During this survey, the following residents reside in B1 through B16: R1, R2, R3, R4, R6, R8, R14, R16, R20, R21, R22, R23, R27, R31, R33, R34, R39, R41, R43, R45, R47, R49, R53, R55, R58, R59, R60, R62, R64, R65, R218. During this survey, they were no observations made regarding adequate nursing care, comfort, and privacy for the who resident in 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.

    Environmental Deficiencies · Deficient, Provider has plan of correction

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

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
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

Paying with Medicaid

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.

Typical monthly cost in Illinois
$8,304/mo
Nursing home (semi-private)
$9,216/mo
Nursing home (private)
$6,219/mo
Assisted living

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 14E847. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-29, 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.

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