Iroquois Resident Home, The
200 Fairman Avenue, Watseka, IL 60970 · Non profit - Corporation · 35 certified beds · (815) 432-7768 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0600), cited Oct 2023
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has citations for mishandling residents’ money or property (F0567, F0568, F0570)
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
- 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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 2 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 improved from 3 to 4 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 | 24.0% | 13.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.1% | 6.3% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 3.8% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 32.7% | 54.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.8% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 25.6% | 14.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 16.2% | 18.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.4% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 30.8% | 20.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.6% | 21.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 84.0% | 63.1% | 79.4% | typical |
| Long-stay hospitalizations per 1,000 resident days | 0.75 | 2.02 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.25 | 2.22 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.62 therapist hours per resident per day in 2026Q1 — more than 89% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.5%CMS range 7.2–16.0 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.75 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 35 beds and averages 33.4 residents a day — about 95% 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 4.03 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.87 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.70 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.60 hrs/resident/day on weekends vs 4.21 on weekdays — 14% thinner on weekends. RN hours go from 0.92 to 0.73 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
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.
26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · F2024-06-26 · 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 an Infection Preventionist. This failure has the potential to affect all 27 residents residing in facility. Findings include: The facility Daily Midnight Census dated 6/24/24 documents 27 residents residing in the facility. Observations were made during Annual Licensure and Certification survey from 6/24/24/-6/26/26 with no Infection Preventionist onsite. On 6/25/24 at 12:45 PM V2 Director of Nurses (DON) stated the facility does not currently have an Infection Preventionist (IP). V2 DON stated the previous IP left the facility a month ago. V2 stated V2 is planning on signing up for the IP class but has not yet. On 6/26/24 at 9:05 AM V1 Administrator confirmed the facility does not currently have an Infection Preventionist. V1 Administrator stated I know we (facility) are small but having an IP would be a great benefit. We (facility) do have residents who are prescribed antibiotics, who are on contact isolation and staff who need education and monitoring for proper Personal Protective Equipment (PPE).…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-26 · 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
Based on observation, interview, and record review the facility failed to assess, treat, and notify the physician of newly acquired pressure ulcers and apply a physician ordered treatment for one of one (R23) resident reviewed for pressure ulcers on the sample list of 18. Findings include: On 6/24/24 at 1:25 PM, R23 was sitting in a recliner in his room. R23 stated he was having terrible pain to his bottom. R23 stated, It's sore! On 6/26/24 at 10:00 AM, V8 Certified Nurse's Assistant stated that she worked on Sunday (6/23/24) and noticed that R23 had open areas to his buttocks and coccyx. V8 stated she notified V10 Licensed Practical Nurse about the open areas. V8 stated she worked Sunday (6/23/24), yesterday (6/25/24), and today (6/26/24) and has not seen a treatment on R23's buttocks or coccyx. On 6/26/24 at 10:10 AM, a dime sized pressure ulcer was present to the left of R23's coccyx, an eraser head sized pressure ulcer was present to the right of R23's coccyx, and a thick, red, raised area of skin containing scattered open areas was present on R23's left buttock along the entire…
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 · D2024-06-26 · 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 and record review the facility failed to implement fall prevention interventions, complete thorough fall investigations to determine root causes and failed to complete Neurological Assessments post falls for two (R2, R25) residents out of two residents reviewed for accidents in a sample list of 18 residents. Findings include: 1.) R2's undated Face Sheet documents R2's medical diagnoses as Cellulitis of the Right Lower Limb, Chronic Obstructive Pulmonary Disease (COPD), Atrial Fibrillation, Weakness, Repeated Falls and Altered Mental Status. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as severely cognitively impaired. This same MDS documents R2 as requiring moderate assistance for toileting, bed mobility and transferring. R2's Fall Risk assessment dated [DATE] documents R2 as a high risk for falling. R2's Care Plan intervention dated 3/22/24 instructs staff to anticipate and meet the needs of the resident. This same care plan documents R2 should be offered toileting every two hours…
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 · D2024-06-26 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, and record review the facility failed to position urinary drainage bags in a manner that prevented potential cross contamination for two of two residents (R23, R230) reviewed for catheters on the sample list of 18. Findings include: The facility's Catheter Care Handling policy with a revision date of August of 2022 documents to ensure catheter tubing and drainage bags are kept up off of the floor. 1. On 6/24/24 at 1:25 PM, R23's urinary drainage bag was clipped to the side of a trash can. This drainage bag was not covered and the bottom of the bag was sitting directly on the floor. On 6/26/24 at 11:16 AM, V2 Director of Nursing (DON) stated all urinary drainage bags should be covered and not touching the floor. 2. On 6/24/24 at 2:02 PM, R230 was sitting in a recliner. R230's urinary drainage bag was hooked to the side of the recliner. The urinary drainage bag was not covered and the bottom of the bag was touching the floor. On 6/26/24 at 11:16 AM, V2 DON stated that urinary drainage bags should be below the bladder but not touching the floor.
- Potential for harm · D2024-06-26 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
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 one (R2) resident for the use of side rails out of one resident reviewed for side rails in a sample list of 18 residents. Findings include: R2's undated Face Sheet documents R2's medical diagnoses as Cellulitis of the Right Lower Limb, Chronic Obstructive Pulmonary Disease (COPD), Atrial Fibrillation, Weakness, Repeated Falls and Altered Mental Status. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as severely cognitively impaired. This same MDS documents R2 as requiring moderate assistance for toileting, bed mobility and transferring. R2's Electronic Medical Record (EMR) does not document a side rail assessment for R2. On 6/25/24 at 2:00 PM R2 was laying in his bed with both siderails in the up position. On 6/26/24 at 10:35 AM V5 Minimum Data Set (MDS) Coordinator stated R2 has never been assessed for siderails. V5 stated (R2) should not have those side rails on his bed. We (facility) are taking them off. The facility policy…
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 · D2024-06-26 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 psychotropic medication consents, assess the need for psychotropic medications, determine symptoms or behaviors warranting use, utilize nonpharmacological interventions, monitor for adverse reactions, establish a psychotropic care plan, and establish parameters for the use of an as needed antianxiety medication for three (R230, 231, 232) of three residents reviewed for psychotropic medications on the sample list of 18. Findings include: The facility's Psychotropic Medication Protocol policy dated 8/31/2022 documents psychotropic/psychoactive medications will not be prescribed without the informed consent of the resident, the resident's guardian, or other authorized representatives, and will be provided with and have signed an Informed Consent for Psychotropic Medications. Information will also be provided with given information regarding the need for, the desired effects and the potential side effects of the medication. Residents will not 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.
- Potential for harm · D2024-06-26 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to implement Enhanced Barrier Precautions (EBP) for three residents (R23, R25, R230) out of four residents reviewed for Infection Control in a sample list of 18 residents. Findings include: 1. R25's Physician Order Sheet (POS) dated June 2024 documents a physician order starting 4/17/24 for Jevity 1.5 calorie/Fiber liquid. Give 355 milliliters (ml) via Gastrostomy tube (G-Tube) every shift for nutritional supplement. Flush with 50 milliliter (ml) water before and after each feeding. On 6/24/24 at 10:30 AM R25's Electronic Medical Record (EMR) documents R25 has a Gastrostomy tube (G-tube) in use. R25's room was not identified with an Enhanced Barrier Precaution sign. There was no Personal Protective Equipment (PPE) available to enter R25's room. No isolation disposal bins were located in or near R25's room. On 6/25/24 at 2:45 PM V9 Licensed Practical Nurse (LPN) completed R25's Gastrostomy tube (G-tube) dressing change. V9 LPN did not wear Personal Protective Equipment (PPE) gown during R25's G-tube dressing…
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 · D2024-06-26 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
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 follow their Antibiotic Stewardship Protocol by administering a prophylactic antibiotic for one of four residents (R10) reviewed for Infection Control in a sample list of 18 residents. Findings include: R10's undated Face Sheet documents R10's medical diagnoses as: Alzheimer's Disease, Dementia and a personal history of Urinary Tract Infections (UTI). R10's Minimum Data Set (MDS) dated [DATE] documents R10 as severely cognitively impaired. R10's Physician Order Sheet (POS) dated June 2024 document a physician order starting 12/24/23 for Cephalexin 250 milligrams (mg) daily for recurrent Urinary Tract Infections (UTI). R10's Medication Administration Record (MAR) dated June 2024 documents R10 was administered Cephalexin 250 mg daily for the month of June, 2024. The facility antibiotic tracking log dated January-June 2024 documents R10 was on Cephalexin 250 mg daily prophylactically for a history of UTI's. On 6/25/24 at 1:30 PM V2 Director of Nurses (DON)…
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 · D2024-06-26 · tag F0909 — failed to maintain a comfortable temperature — isolatedRegularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
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 bed rails were safely attached to a bed for one of one resident (R2) reviewed for side rails in a sample list of 18 residents. Findings include: R2's undated Face Sheet documents R2's medical diagnoses as Cellulitis of the Right Lower Limb, Chronic Obstructive Pulmonary Disease (COPD), Atrial Fibrillation, Weakness, Repeated Falls and Altered Mental Status. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as severely cognitively impaired. This same MDS documents R2 as requiring moderate assistance for toileting, bed mobility and transferring. R2's Physician Order Sheet (POS) dated June 2024 documents a physician order starting 3/15/24 for bed rails for bed mobility and positioning. R2's Fall Risk assessment dated [DATE] documents R2 as a high risk for falling. On 6/24/24 at 9:35 AM R2 was laying in bed with both legs hanging off of mattress from knees to feet. R2's quarter bed rail on the same side of bed was hanging at a 45…
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 · D2024-04-18 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to timely report an allegation of sexual abuse to the Administrator for two of three residents (R1, R2) reviewed for sexual abuse on the sample list of three. Findings Include: The facility's Serious Injury Incident and Communicable Disease Report dated 4/10/24 at 12:15 pm documents, on 4/9/24 at 12:45 pm, R2 leaned over and kissed R1 on the lips. Since both R1 and R2 have a very low BIMS (Brief Interview for Mental Status) score; R1 being a 1 {indicating severe cognitive impairments} and R2 being a 4 {indicating severe cognitive impairments}, the intervention in place is to make sure that residents are watched and separated to prevent this from happening again. On 4/17/24 at 11:09 am, V1 (Administrator) stated on 4/10/24, V8 CNA (Certified Nursing Assistant) came up to V1 and asked V1 if V1 was aware of what happened on 4/9/24 between R1 and R2. V1 explained V1 was unaware of anything happening, then V8 reported that V8 had been told that R2 kissed R1. V1 stated V8 did not know any of the specifics though and told V1 to talk…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 16 citations
- Potential for harm · D2024-04-18 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to thoroughly investigate an allegation of sexual abuse for two of three residents (R1, R2) reviewed for sexual abuse on the sample list of three. Findings Include: The facility's Serious Injury Incident and Communicable Disease Report dated 4/10/24 at 12:15 pm documents, on 4/9/24 at 12:45 pm, R2 leaned over and kissed R1 on the lips. Since both R1 and R2 have a very low BIMS (Brief Interview for Mental Status) score; R1 being a 1 {indicating severe cognitive impairments} and R2 being a 4 {indicating severe cognitive impairments}, the intervention in place is to make sure that residents are watched and separated to prevent this from happening again. The Investigation only contained witness statements from R1, R2, V4 CNA (Certified Nursing Assistant), V3 Secretary, and V10 RN (Registered Nurse). No other residents were interviewed. On 4/17/24 at 11:09 am, V1 Administrator stated the only residents that were interviewed were R1 and R2, the two residents involved in the allegation. V1 stated no other residents were around but…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-07 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident (R1) was not subjected to verbal abuse by an employee. R1 is one of three residents reviewed for abuse on the sample list of five. Findings include: On 10/7/23 at 11:24am V3 Certified Nursing Assistant (CNA) said, on 9/20/23 at 2:00pm V4 Certified Nursing Assistant (CNA) was preparing R1 for a shower in R1's room. V3 said, V3 heard V4 tell R1 that if R1 doesn't stop yelling, V4 will drown R1 in the shower. V3 said, V4 gave R1 a shower, and brought R1 back to R1's room. V3 said, V3 than heard V4 tell R1 to shut the (expletive) up, because R1 was yelling out. V3 said, V3 immediately went and told V2 Director of Nursing (DON). On 10/7/23 at 1:15pm V1 Administrator said, on 9/20/23 V1 was notified of an allegation of abuse between R1 and V4 Certified Nursing Assistant (CNA). V1 said, V1 interviewed V3 Certified Nursing Assistant (CNA) who informed V1 that on 9/20/23 at 2:00pm V4 Certified Nursing Assistant (CNA) was preparing R1 for a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-05-04 · 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 interview and record review, the facility failed to ensure the facility was sufficiently staffed to meet the needs of the residents. This failure affects five residents (R5, R14, R20, R23, R28) on the sample list of 21. This failure has the potential to affect all 28 residents residing in the facility. Findings include: The facility's Resident Council Meeting Minutes documents the following nursing concerns: 4/19/22 residents would like more Certified Nursing Assistants (CNA's) on evening shift. On 5/19/22 residents would like more CNA's. 6/16/22 one resident stated was not getting their bath today because not enough staff. Residents say we are understaffed for CNA's on early evenings and weekends. 7/14/22 one resident stated sits too long when going to the bathroom around meal times and residents state would like more CNA's. 9/26/22 residents have concerns that there are not enough to help out in case of an emergency and complaints that CNA's like to stand around and visit when they hear call lights go off. 10/13/22 residents stated they need more CNA's. Resident stated…
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 before2023-05-04 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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, record review, and interview, the facility failed to ensure the dishwashing machine was operating in a manner to sanitize residents food service dishes, wares, and utensils. This failure has the potential to affect all 28 residents residing in the facility. Findings include: On 5/3/23 at 9:06 am, V12, Dietary Aide, stated, The dishwasher is a high temp (temperature) machine, I check it every morning. V12 then placed a facility digital thermometer onto a dishwashing rack and ran the rack through a cycle in the dishwasher. The thermometer displayed the maximum temperature during the dishwashing cycle of 144 degrees Fahrenheit (F). The facility's 'Commercial Rack Conveyor Dish Machine Manufacturer Instructions' dated 6/15/1999 documents the minimum wash temperature for hot water sanitization should be 150 degrees F, the pumped rinse minimum temperature should be 160 degrees F, and the final rinse minimum temperature should be 180 degrees F. On 5/3/23 at 9:09 am, V12, Dietary Aide, stated to V11, Dietary Aide, When I checked the temperature this morning it was 152…
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 · D2023-05-04 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 accurately complete a comprehensive resident assessment for one (R20) resident reviewed for resident assessments on the sample list of 21. Findings include: R20's Face Sheet dated 5/4/23 documents diagnoses including Type 2 Diabetes Mellitus and End Stage Renal Disease. R20's Minimum Data Set (MDS) quarterly assessment dated [DATE] documents the following: Section O- Special Treatments, Procedures, and Programs: J. Dialysis 2. While a Resident- Yes and was signed by V4 Assistant Director of Nursing (ADON). R20's MDS Summary documents R20's 2/9/23 MDS was accepted on 2/17/23. R20's Electronic Medical Record does not document R20 on dialysis or receiving dialysis while a resident at the facility. On 5/2/23 at 10:51am, R20 stated R20 has never been on dialysis. On 5/2/23 at 10:57am, V2 Director of Nursing stated R20 has not been on dialysis since V2's starting working there. V2 stated the facility does not have any residents on dialysis and does not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-04-22 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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, record review, and interview, the facility failed to maintain kitchen equipment to prevent the potential for cross contamination of food. This failure has the potential to affect all 32 residents residing in the facility, all of whom consume food prepared in the facility kitchen. Findings include: On 4/19/22 at 10:51 am, the facility's cooking range vent hood had more than fifteen dark brown greasy streaks with grease trails down the metal slats of the vent hood. These greasy streaks each terminated on the bottom edge of the vent hood with hanging drops and drips of the dark brown grease. The vent hood, and hanging grease drops, were directly over the cooking surfaces, burners, and grill surface of the cooking range. The vent hood and hanging grease drops were also directly over heating and warming ovens. On 4/19/22 at 10:51 am, V4, Kitchen Coordinator/ Manager, touched a fingertip to one of the hanging grease drops and rubbed the dark brown greasy material between two fingers and stated, I have never noticed that. The range vent hood had a sticker placed on…
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 · E2022-04-22 · tag F0567 — failed to protect residents' money held by the home — patternHonor the resident's right to manage his or her financial affairs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to obtain written authorization to manage resident's personal funds, and failed to deposit resident's, whose care is funded by Medicaid, personal funds over $50.00 in an interest bearing account. This failure affects six residents (R3, R6, R15, R19, R31, and R233) out of six reviewed for personal funds management on the sample list of 23. Findings include: On 4/20/22 at 3:55 pm, V1, Administrator, stated, We don't really have a resident trust fund, with the exception of one of our residents, (R6), who has a trust account managed by the fiscal department from the hospital side of the building. (R6) is a Medicaid recipient and is under a state guardianship. V1 continued, What we do have is money we keep locked in the safe inside the medication room for residents who want to be able to use cash for something while they are here. V1 further stated, We are not the representative payee for any resident. The families do bring in money for some of our residents and we accept those funds for them, and we do provide that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-04-22 · tag F0568 — patternProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to provide quarterly statements to residents or their representatives to account for resident's personal funds entrusted to the facility on the resident's behalf. This failure affects six residents (R3, R6, R15, R19, R31, and R233) out of six reviewed for personal funds on the sample list of 23. Findings include: On 4/20/22 at 3:55 pm, V1, Administrator, stated, We don't really have a resident trust fund, with the exception of one of our residents, (R6), who has a trust account managed by the fiscal department from the hospital side of the building. (R6) is a Medicaid recipient and is under a state guardianship. V1 continued, I receive statements for (R6's) Trust Account. V1 further stated, The facility is not a representative payee for any resident. On 4/20/22 at 3:59 pm, the facility's Personal Cash Box Inventory (individual accounting sheets) documents R3 had a balance of cash in the amount of $16.94, R6 had a cash balance of 45 cents, R15 had a cash balance of $26.00, R19 had a cash balance of $286.40, R31…
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 · E2022-04-22 · tag F0570 — patternAssure the security of all personal funds of residents deposited with the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to maintain a surety bond, or other financial security, in an amount sufficient to protect all resident funds deposited with the facility. This failure affects six residents (R3, R6, R15, R19, R31, and R233) out of six reviewed for personal funds on the sample list of 23. Findings include: On 4/20/22 at 3:55 pm, V1, Administrator, stated, We don't really have a resident trust fund, with the exception of one of our residents, (R6), who has a trust account managed by the fiscal department from the hospital side of the building. V1 further stated, We do have some resident's money locked in our safe in the medication room for safekeeping for when a resident wants to spend something for themselves. On 4/20/22 at 3:59 pm, the facility's Personal Cash Box Inventory (individual accounting sheets) documents R3 had a balance of cash in the amount of $16.94, R6 had a cash balance of 45 cents, R15 had a cash balance of $26.00, R19 had a cash balance of $286.40, R31 had a current zero balance, however, did have a cash balance…
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 · D2022-04-22 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 obtain and document Physician Orders for resident advance directives. This failure has the potential to affect one of three residents (R83) reviewed for advanced directives in the sample of 23. Finding include: R83's Current Physician's Orders (POS) do not document an order for Do Not Resuscitate (DNR) or Cardiopulmonary Resuscitation (CPR). R83's electronic medical record does not include an Illinois Department of Public Health (IDPH) Uniform Practioner Order for Life-Sustaining Treatment (POLST) Form. This form is used to document a resident's preference for life sustaining treatment. R83 has not completed this form since being admitted to the facility. The facility's policy with the revision date of 3/2020 titled Advance Directives and Psychiatric Advance Directives states section labeled POLICY: It is our policy to comply with these laws by honoring the treatment preferences expressed by our patients in their Advance Directives. Staff (inpatient and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-04-22 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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 required Advanced Beneficiary Notices to residents having their Medicare Part A services terminated, precluding residents from selecting the options to continue these services by billing Medicare for an appeal, or at their own expense. This failure affects two residents (R6 and R29) out of three reviewed for Beneficiary Protection Notification on the sample list of 23. Findings include: 1) R6's Census Detail dated 4/21/22 documents R6 began to receive services under Medicare Part A benefits on 1/6/22, and subsequently had Medicare Part A services terminated on 1/17/22. This same Census Detail documents R6 remained in the facility after the termination of Part A services and was a current resident at the time of the survey. R6's Beneficiary Protection Notification Review Form, undated, completed by the facility's Social Services Designee, V9, documents R6's Medicare Part A services were terminated by the facility 1/17/22, and R6 was not issued an Advance Beneficiary Notice (ABN) because (R6) was At prior level, no…
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 · D2022-04-22 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the facility failed to provide resident (R14) a facility Bed Hold Policy when being discharged to the hospital. R14 is one of one resident reviewed for Bed Hold Notices in the sample of 23. Findings include: R14's Diagnosis Sheet dated 4/22/22 includes the following diagnosis: Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris and Acute Respiratory Failure with Hypoxia. R14's progress note dated 4/8/22 documents R14 was sent to emergency room for shortness of breath and chest tightness oxygen saturation was 48% DuoNeb given oxygen applied at 4 liters nasal cannula was able to get oxygen saturation to 59%. The Census for R14 shows R14 was transferred to the hospital on 4/8/22. R14's electronic medical record does not have any bed hold form available documenting R14 was transferred to the hospital and offered bed hold. The facility's policy titled Discharge or Transfer of Resident dated November 2003 documents. Section F : Hold Bed/readmission: 1. Hold bed a) Family or Resident will notify staff that bed is to be 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.
- Potential for harm · D2022-04-22 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
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 encode, format, and transmit a resident's Minimum Data Set for discharge from the facility. This failure affects one resident (R1) out of 12 reviewed for Minimum Data Sets on the sample list of 23. Findings include: R1's Nurse's Progress Note dated 11/8/21 document a care plan meeting with the resident's (2 family members, V13 and V14), the facility's Therapy Staff (un-named), Assistant Director of Nursing, Registered Dietician, Social Services Designee, and Activity Director, to arrange home services for R1's pending discharge from the facility. R1's Nurse's Progress Note dated 11/10/21 documents nursing staff arranged a post-discharge follow-up appointment for R1. R1's Nurse's Progress Note dated 11/11/21 documents R1 was discharged from the facility and left the building accompanied by V14, Family Member. R1's Census Detail documents and confirms R1 was discharged from the facility 11/11/21. R1's Minimum Data Set List dated 4/20/22 documents there…
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 · D2022-04-22 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop and implement a resident's comprehensive care plan, documenting resident needs and services required to meet those needs. This failure affects one resident (R29) out of 12 reviewed for care plans on the sample list of 23. Findings include: R29's Census Detail dated 4/21/22 documents R29 was admitted to the facility on [DATE] under Medicare Part A services. This same Census Detail documents R29 had changed payer source to Medicaid on 4/9/22 and remained in the facility as a resident. R29's Minimum Data Set (MDS) list documents R29 entered (entry MDS) the facility 3/16/22. This same MDS List documents a comprehensive resident assessment completed on 3/22/22. R29's Care Plan dated 4/20/22 documents one Focus area for: The resident has a nutritional problem or potential nutritional problem r/t (related to) potential decrease in intake due to environment change. R29's Medical Diagnoses List includes Iron Deficiency Anemia, Urinary Tract 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 · Dcited before2022-04-22 · 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
Based on record review, interview and observation, the facility failed to monitor a resident's (R20) pressure ulcer and failed to complete a proper dressing change of R20's pressure ulcer. R20 is one of one resident reviewed for pressure ulcers in the sample of 23. Findings include: R20's Diagnoses Sheet (current) includes the following diagnoses: Hospice, Congestive Heart Failure, End Stage Renal Disease and Diabetes Mellitus. R20's Physician Order Sheet (POS) dated April 2022 documents the following order: Cleanse Wound with Normal Saline and pat dry, Apply Misoprostol 0.0024% / Lidocaine 2% / Phenytoin 5% Cream topically to affected area daily and cover with primapore dressing. R20's Care Plan (current) documents the following: (R20) has Potential for Skin Breakdown: Stage 2 (Right) Buttock, Weekly Treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate with any other notable changes and observations. Skin/Wound Assessments for R20 are documented as follows: 2/12/22 - Coccyx - Superficial loss of skin, Pink…
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 · C2022-04-22 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to post the required nurse staffing data on a daily basis and failed to maintain the required nurse staffing data for 18 months. This failure has the potential to affect all 32 residents residing in the facility. Findings include: On 4/19/22 at 2:45 pm, there was not a daily nurse staffing posting anywhere in the facility. On 4/19/22 V1, Administrator, stated, I am going to be honest with you, we are not real good about getting the posting up there, but this is the plastic holder where it should be. V1 pointed to a plastic holder on the wall next to a large bulletin board and stated, Today it is empty. On 4/22/22 at 12:35 pm, the daily nurse staffing posting was dated from 4/21/22. On 4/22/22 at 12:35 pm, V1, Administrator, stated, My ADON (Assistant Director of Nursing) called in sick today so I am looking for the blank posting sheets on her desk. I don't know if we have kept 18 months of those postings because I have only worked here since January. I know there is about 4 boxes of all kinds of paperwork but I…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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 |
|---|---|---|---|
| DITTRICH, ROGER | Individual | CORPORATE DIRECTOR | since 12/21/2024 |
| KNAPP, ADAM | Individual | CORPORATE DIRECTOR | since 01/01/2025 |
| MIKUTA, SARA | Individual | CORPORATE DIRECTOR | since 07/01/2024 |
| PENCE, RHONDA | Individual | CORPORATE DIRECTOR | since 02/01/2014 |
| REYES, CRISANTO | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | since 02/12/2025 |
| TINCHER, DANIEL | Individual | CORPORATE DIRECTOR | since 07/01/2024 |
| ZUMWALT, PHILIP | Individual | CORPORATE DIRECTOR | since 07/26/2022 |
| TILSTRA, MICHAEL | Individual | CORPORATE OFFICER | since 01/17/2022 |
| FOX, MICHELLE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/01/2018 |
| GRAVES, DENISE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/27/2025 |
CMS files one row per role, so the 13 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
What families pay in IL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. 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 146049. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-06-26, 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 →
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