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Waukegan Health And Rehab

2217 Washington Street, Waukegan, IL 60085 · For profit - Limited Liability company · 112 certified beds · (847) 244-4100 Medicare & Medicaid certified

Call the home — (847) 244-4100 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Apr 20262 actual-harm citations$8,328 in federal fines1 Medicare payment denial
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2026
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0605, 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
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,328 in federal fines (most recent 2023-11-15)
  • its facility-reported quality-measure rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

Location & what’s nearby

Hospital
Urgent care / clinic
2504 Washington St · (847) 662-4455 · Call to confirm hours
Pharmacy
10 S Lewis Ave · (847) 623-9087 · Call to confirm hours
Grocery
2005 Washington St · (847) 623-5401 · Call to confirm hours
Park
2000 Belvidere Rd · (847) 360-4700 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 1 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 held steady at 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.

Overall rating4★
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 increased8.1%13.4%15.4%better
Long-stay residents who lose too much weight2.3%6.3%5.4%better
Long-stay residents with a catheter left in their bladder1.4%0.9%0.9%worse
Long-stay residents with a urinary tract infection4.8%1.5%2.0%worse
Long-stay residents with depressive symptoms49.4%54.2%6.5%typical for the 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 injury1.0%3.1%3.3%better
Long-stay residents whose ability to walk worsened3.5%14.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication16.6%18.3%18.9%better
Long-stay residents given the seasonal flu vaccine87.2%91.8%95.3%typical
Long-stay residents with pressure ulcers4.2%4.8%4.7%better
Long-stay residents with worsening bladder/bowel control30.5%20.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table23.7%21.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.8%2.2%1.4%worse
Short-stay residents given the seasonal flu vaccine8.2%63.1%79.4%worse
Short-stay residents rehospitalized after admission16.8%26.1%22.6%better
Short-stay residents with an outpatient ER visit14.4%13.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days3.422.021.67worse
Long-stay outpatient ER visits per 1,000 resident days2.032.221.80worse

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.

30.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 53 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

30.5%U.S. median 51.5%
Got home and stayed home
11.9%U.S. median 10.7%
Went back to hospital
23.5%U.S. median 56.6%
Met the expected recovery
0.19U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.05hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 23.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 34 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.19 therapist hours per resident per day in 2026Q1 — more than 20% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 30% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF30.5%CMS range 23.1–44.051.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.9%CMS range 8.2–16.610.7%Oct 2022–Sep 2024no 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 discharge23.5%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge23.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge23.5%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified89.1%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting96.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this 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 dischargenot 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 stay3.1%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.7%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.6%CMS range 4.8–14.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.511.02Oct 2022–Sep 2024CMS 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

0.83
RN hours/ resident / day
0.39
LPN hours/ resident / day
1.86
Aide hours/ resident / day
3.07
Total nurse hours/ resident / day
0.68
RN hoursweekends
40.8%
Total nursing turnover
26.7%
RN turnover

How full it usually is: this home is certified for 112 beds and averages 78.8 residents a day — about 70% occupied, or roughly 33 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.07 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.83 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.86 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 2.60 hrs/resident/day on weekends vs 3.27 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.89 to 0.68 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 41% is about the same as the national median of 45%.

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

Inspection trend

9
deficiencies at the latest standard inspection (2025-05-21)
4
at the previous standard inspection (2024-06-12)

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.

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.

27 citations, most serious first. The 12 most serious are shown; the remaining 15 are one tap away and print in full.

  • Actual harm · Gcited before2023-12-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to safely transfer a resident (R1). This failure resulted in R1 being hit in the head with the arm of the mechanical lift, resulting in a large skin tear, being admitted to the hospital, and requirng sutures to her head. This applies to one of three residents (R1) reviewed for safety in the sample of five. The findings include: The facility assessment dated [DATE] shows R1 to be cognitively intact, requires maximum assistance for her activities of daily living and uses a mechanical lift for her transfers. On 12/21/23 at 11:15 AM, R1 said she was being lifted from her bed to her wheelchair using the mechanical lift. R1 said as she was being lowered to her wheelchair, the arm bar on the lift hit her in the head. R1 said she saw stars and was in a lot of pain. R1 said she had to be taken to the hospital for sutures, and had to spend the night and have scans to her brain to rule out a brain injury. R1 said she was very scared and in a lot of pain…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2023-11-30 · 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 ensure a resident was assisted in safe manner to prevent injury for 1 of 3 residents (R1) reviewed for safety in the sample of 4. This failure resulted in (R1) sustaining a fall and receiving a right ankle fracture. The findings include: R1's face sheet shows she has diagnoses including: Parkinsonism, anxiety disorder, auditory and visual hallucinations, and a history of falls. R1's current care plan shows on 10/6/23 Impaired Memory care plan was initiated which says R1 is having impaired memory and problems with decision-making, insight, logic, calculation, reasoning, planning and judgement. R1's active Fall Risk care plan initiated 3/9/17 shows R1 is at risk for falls and she requires a one person assist for transfers. R1's active Transfer-Restorative care plan initiated on 3/9/17 shows R1 is unable to transfer independently and requires a one person assist and a gait belt for transfers. R1's Physical Therapy Progress Report from 10/27/23-11/13/23…

    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 · D2026-04-29 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to protect the resident's right to be free from physical abuse by another resident for 1 of 2 residents (R1) reviewed for abuse in the sample of 7. The findings include:R1's face sheet showed he was admitted to the facility 3/17/26 with diagnoses to include senile degeneration of brain, cellulitis of left upper limb, dementia, muscle weakness, and atrial fibrillation. R1's facility assessment dated [DATE] showed he has severe cognitive impairment and requires substantial to maximum assist of staff for most cares. R1's Care Plan initiated 3/20/26 showed, The resident's memory is impaired. Consequently, the resident has problems with decision-making, insight, logic, calculation, reasoning, planning, and judgement. R1's Care Plan initiated 4/2/26 showed, the resident has a history of behavior problem such as hitting staff related disease process. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner.…

    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 · Dcited before2025-12-02 · 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 implement safety interventions for 2 of 2 residents (R1, R2) reviewed for safety in the sample of 3. This failure resulted in R1 being hit in the face by R2's involuntary movements. The findings include: R1's face sheet printed on 12/2/25 showed diagnoses including but not limited to Alzheimer's disease, non-traumatic brain dysfunction, and mood disorder. R1's facility assessment dated [DATE] showed R1 has severe cognitive impairment and uses a wheelchair. R1's progress note dated 11/25/25 stated: At around 6:30 pm resident was sitting near the first-floor nurses' station next to a male resident who struck her on the right side of her face. Writer immediately separated the residents and assessed resident's eye and face, there appeared to be no injury, 911 called,. Progress notes showed R1 was transported to the local emergency room and returned the same day without injury. R2's face sheet printed on 12/2/25 showed diagnoses including but not limited to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-10-28 · tag F0675 — failed to support quality of life — isolated
    Honor each resident's preferences, choices, values and beliefs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide R1 with the necessary care and services to maintain the highest practicable physical and psychosocial well-being for 1 of 6 residents (R1) reviewed for quality of care in the sample of 6.The findings include:On 10/27/25 at 10:35AM, R1 was lying in bed watching television. R1 sat up on the side of the bed and placed her feet on the floor. R1 said, a couple of weeks ago one of the CNAs (Certified Nursing Assistant) took my vital signs and said, I am going to help you with your shower. I told the CNA I can do it myself. I have been here 5 years and only needed someone to help me with my back. The CNA's hands were all over me. I told the CNA to stop. The CNA said, take it easy. In the past, the staff would provide privacy while I washed myself. The staff may have washed my back, now I have a back brush; no one is touching me again. When the CNA started washing me. I told the CNA to stop. The CNA thought I was being funny. I said, you…

    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 before2025-05-21 · 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 ensure safe food handling practices were followed to prevent cross-contamination. This has the potential to affect all residents that receive food and nourishments from the kitchen. The findings include: Centers for Medicare and Medicaid form 671 dated 5/19/25, shows there are 88 residents that reside in the facility. On 5/21/25 at 10:40 AM, V10 (Director of Culinary Services) said at this time, all residents residing in the facility receive food, beverage, or nourishment from the kitchen at this time; even those receiving a tube feeding because they are ordered pleasure feeding. 1. On 5/19/25 at 11:25 AM, V11 (Cook) dropped a white cleaning towel onto the floor. V11 picked up the towel and continued to wipe down the food prep counter next to the oven, wipe down and clean a thermometer, clean down the prep counter that attaches in front of the steam table, and then placed the towel by the three-compartment sink. On 5/19/25 at 11:36 AM, V10 began the mechanical soft chicken process and used a green handle scoop…

    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 · E2025-05-21 · 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 bathroom was clean and homelike. This applies to 4 of 4 residents (R48, R50, R56, R60) in the sample of 18. The findings include: On 5/20/25 at 9:31 AM, during the resident council meeting, R48, R50, R56 and R60 said the first bathroom/shower room looks like there is mold on the ceiling, it's been like that for a while. There has been no maintenance staff over a month to fix repairs, the last one was fired. On 5/20/25 at 10:06 AM, in the bathroom/shower room on the first floor a brown/yellowish discoloration of dried water rings with pieces of peeled paint and drywall hanging from the ceiling above the toilet. On 5/21/25 at 10:55 AM, V1 (Administrator) said we don't have a maintenance staff right now, our permanent maintenance staff left in October 2024, since then we have hired a couple of new maintenance staff and they have not worked out. The bathroom ceiling does not have mold, there was a leaky toilet upstairs on the 2nd floor that caused the damage. We were waiting to repair the ceiling after…

    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 · D2025-05-21 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    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 anti-psychotic psychotropic medications had a stop date of 14 days for 1 of 6 residents (R15) reviewed for unnecessary medications in the sample of 18. The findings include: R15's face sheet shows she has diagnoses including cerebral infarction, unspecified dementia with psychotic disturbance and hemiplegia and hemiparesis. R15's Electronic Medical Record (EMR) shows she entered hospice care on 1/28/25. A Hospice Interdisciplinary Plan of Care completed on 3/20/25 shows an order for R15 to receive Risperdal (risperidone) (Anti-psychotic medication) 1 milligram (mg.) every morning and to continue PRN (as needed) Risperdal 0.5 mg. every 8 hours for agitation. There is no stop date identified. R15's EMR shows the hospice order for the PRN Risperdal was entered into the Physicians Orders with the following statement added, Do not discontinue without discussing with Hospice. A facility provided a not dated Medication Regimen Review Prescriber Recommendations shows the pharmacy had notified the facility on this form of 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-21 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to ensure a resident's splint/palm protector was in place to her left hand for 1 of 4 residents (R36) reviewed for splints/restorative care in the sample of 18. The findings include: On 5/19/25 at 10:30 AM R36 was in bed, asleep with no splint on her left hand. Again on 5/20/25 at 9:00 AM at 12:49 PM R36 was in bed with no splint on her left hand. R36's left hand is contracted in a closed fist position with her fingers pressing into her palm. On 5/20/25 at 12:55 PM V9 (Agency Certified Nursing Assistant) was asked about R36's left hand splint. V9 stated she didn't know anything about it and proceeded to take R36 out of the room in her reclining wheelchair and placed her in the dining room. On 5/21/25 at 9:32 AM V8 (Restorative Nurse) stated, I didn't know she didn't have it. It is a palm protector to keep her fingers from pressing into her palm. She takes it off with her other hand. I don't know where is was, I asked night shift to find it for me. R36's current Physician's Order Sheet shows an order dated 9/10/24…

    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 · D2025-05-21 · 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

    Based on observation, interview, and record review the facility failed to ensure dietary supplements were provided for 1 of 6 residents (R22) reviewed for weight loss in the sample of 18. The findings include: R22's face sheet shows she has diagnoses including dementia. R22's Weight Summary shows she weighed 116.4 pounds (lbs.) on 4/1/24 and she weighed 108.3 lbs. on 3/3/25 a 8.1 lb. 7.75% weight loss in 1 year. R22's 3/12/24 Dietary Note completed by V12 (Dietician) shows that R22 has had some weight fluctuations possibly due to dementia. The Dietary Note shows that supplements to promote higher protein and calorie consumption had been added prior to the weight change including yogurt 6 ounces with meals, skim milk three times a day with meals, double eggs at breakfast, and a new dietary supplement of peanut butter and jelly sandwiches with meals was added. On 5/19/25 the noon meal service on the 1st floor was observed. At 1:20 PM R22's meal tray was brought out to her, and staff assisted R22 to start eating and sat at the table with her. On R22's meal tray was a copy of her meal…

    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 · D2025-05-21 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to document a numerical value for a peripherally inserted central catheter (PICC) measurements for 1 of 1 resident (R61) reviewed for intravenous (IV) access in the sample of 18. The findings include: R61's face sheet printed on 5/19/25 showed he was a [AGE] year-old male that had the diagnosis of osteomyelitis (bone infection). A facility assessment done on 4/10/25 showed R61's mental status was intact. On 5/19/25 at 12:19 PM, R61 said he was getting IV antibiotics for a bone infection through a PICC that had been removed. R61 said staff did not measure the catheter length or the circumference of his arm. R61's Medication Administration Records (MAR) for April 2025 and May 2025 showed an order to measure the catheter length of the PICC weekly from the insertion site to the tip of the cap and to call the doctor if the length changed more than 2 centimeters. Also, to measure the arm circumference weekly. The measurements were to be done on the following…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-21 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to ensure a resident consumed their medications when administering medications for 1 of 18 residents (R42) reviewed for pharmacy services in the sample of 18. The findings include: R42's Care Plan with an initiated date of 4/24/24 showed R42's memory is or may be impaired. Consequently, the resident has problems with decision-making, insight, logic, calculation, reasoning, planning, and judgement. On 5/19/25 at 9:37 AM, R42 was in bed. On the bedside table was a clear medication cup with 4 pills (one white, one yellow, and two brown). R42 said he had not received his morning medications. R42 was asked about the pills on his bedside table. R42 said he was not aware there were pills sitting on his bedside table. R42 added sometimes staff will leave his medication on the bedside table for him to take later. On 5/19/25 at 10:21 AM, the pills remained on R42's bedside table. On 5/19/25 at 10:50 AM, the pills were no longer on R42's bedside table. On 5/19/25 at 11:09 AM, V5 (Registered Nurse) said he noticed the pills…

    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
Show the remaining 15 citations
  • Potential for harm · D2025-05-21 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to ensure insulin pens were properly stored and labeled for 2 of 18 residents (R60, R78) reviewed for medication storage in the sample of 18. The findings include: On 5/20/25 at 12:17 PM, the first-floor medication cart was reviewed with V15 (Registered Nurse). Inside the medication cart in the top drawer there was a 1/4 full (Lantus) insulin pen that had no resident name or open date on it and a Humalog Kwik pen belonging to R78. The pen was not opened and the packaging the pen was in was clearly labeled Refrigerate. V15 verified the Humalog was a new unopened insulin pen and should be kept in the refrigerator until it is open for use. V15 also was unable to verify whose (Lantus) insulin pen was inside the cart that was not labeled and said all insulin pens should be clearly labeled with who it belongs to and the open date. On 5/21/25 at 7:30 AM, V2 (Director of Nursing) said that the insulin pens should clearly be labeled and dated when opened and any insulin pen that is new should be kept refrigerated until it…

    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 · Dcited before2025-05-21 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to ensure staff wore the required personal protective equipment (PPE) when providing high contact care activities for 2 of 18 residents (R7 and R36) reviewed for infection control in the sample of 18. The findings include: 1. R7's Face Sheet printed on 5/19/25 showed R7 had a gastrostomy (tube feeding). R7's Order Summary Report printed on 5/19/25 showed an order for enhanced barrier precautions related to an indwelling medical device of a tube feeding. On 5/19/25 at 9:50 AM, on R7's door was a sign that indicated R7 was on enhanced barrier precautions. The sign indicated staff were to wear gloves and gown for high contact care such as device care or use of a feeding tube. On 5/19/25 at 9:50 AM, R7 was in bed. V5 (Registered Nurse) was holding R7's tube feeding tubing while connecting a syringe that contained fluid to R7's tube feeding. V5 had on gloves. V5 did not have on an isolation gown. On 5/20/25 at 12:41 PM, V6 (Wound Care Nurse) said staff should put on gloves and gown when providing care or touching an…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to ensure a resident who requires assistance with toileting received incontinence care. This applies to 1 of 4 residents (R47) reviewed for activities of daily living in the sample of 18. The findings include: On 6/11/24 at 9:36 AM, R47 was laying down in her bed. A strong permeating smell of urine was present. R47's gown, bed pad, and bed sheet were soaked with urine. R47 said it takes a long time to get help. At 9:47 AM, V8 (Certified Nursing Assistant) came in the room to assist R47 to the bathroom. V8 stated, your soaking wet, I'm so sorry. V8 said she did not change R47 yet, she was busy. R47 was her last resident who needed to be changed. On 6/12/24 at 9:15 AM, V8 (CNA) said residents should be checked and changed every two hours. The facility's Activities of Daily Living Policy dated 2021, states, the facility will ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. the facility will provide care 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-12 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to apply devices to residents with physical limited mobility to 2 of 2 residents (R37, R61) reviewed for range of motion in the sample of 18. The findings include: 1. R37's Physician Order Sheet (POS) show R37 has diagnoses that include hemiplegia (paralysis) affecting right dominant side due to stroke. The same POS show an order of, Right resting hand splint to right hand. On after breakfast and off after supper daily. remove for grooming, and bathing and prn as needed. Monitor for redness /discomfort or skin changes. R37 also has an order of [R37] to wear sling when up in wheelchair to hold her right arm from falling down to side. On 6/10/24 at 12:36 pm, R37 was in the dining room for lunch. As soon as R37 saw this surveyor R37 used her left hand to lift her right hand showing this surveyor her contracted right hand. V12 Certified Nursing Assistant (CNA) who was with R37 said R37 should have a splint in her right hand. This surveyor asked…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-12 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to ensure a residents prescribed medication was available to administer. This applies to 1 of 7 residents (R6) reviewed for pharmacy services in the sample of 18. The findings include: On 6/11/24 at 9:16 AM, V5 (Licensed Practical Nurse-LPN) during the morning medication pass, Did not administer R6's Depakote 500 mg (milligrams). She said she is out of R6's Depakote and will have to re-order the medication. V5 said she usually re-orders medications when there's about five pills left. If we tell the phamracy we need the medication STAT they will send it right away. R6's Medication Administration Record (MAR) dated June 2024 shows orders for Depakote ER oral tablet extended release give 500 mg two times a day at 9 AM and 5 PM. R6's MAR shows the Depakote was not administered on 6/11/24 (R6 missed two doses). On 6/12/24 at 9:17 AM, V2 (DON) said staff should check the medication convience box if they do not have the medications. V2 said she is not sure if Depakote is located in the convenience box. If the staff do…

    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 · Dcited before2024-06-12 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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, facility failed to wash hands and change gloves in a manner to prevent cross contamination and failed to wear personal protective equipment (PPE) during care on a resident on enhanced barrier precaution to 2 of 18 residents (R8, R61) reviewed for infection control in the sample of 18. The findings include: 1. On 06/11/24 at 9:20 AM, V10 (Certified Nursing Assistant-CNA) provided incontince care to R8. V10 removed R8's incontinent brief that was totally soaked with urine. R8 also had a large bowel movement. After providing incontince care and wearing the same soiled gloves and without performing handwashing V10 applied barrier cream to R8, applied new incontinent brief, turned R8 side to side, adjusted R8 in bed, applied new pants to R8 and pulled R8's privacy curtain. V10 then collected the soiled linens and left R8s' room still without removing her soiled gloves and without washing her hands. On 6/12/24 at 9 AM, V11 (Registered Nurse-RN) said staff should change their gloves and wash hands in between care. Once soiled gloves are…

    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 · D2024-02-13 · tag F0582 — isolated
    Give 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents funds were refunded after discharge for 1 of 6 residents (R1) reviewed for personal funds in the sample of 6. The findings include: R1's electronic face sheet show [AGE] year-old male admitted to the facility on [DATE] with diagnoses that include cervical disc disorder with myelopathy, quadriplegia C1-C4 and diabetes. R1 was discharged more than a year ago-11/22/2022 under medicaid/social security. On 2/13/24 at 12:16 PM, V7 (Business Office) said R1's social security check went to his personal account to pay for his stay at the facility (cost care). V7 said R1 was discharged last 11/22/22. V7 said R1's social security check came on 12/2/22 after R1 was already discharged from the facility. V7 said it was only refunded to R1 approximately 2 weeks ago-1/30/24, (more than a year after R1 was discharged ) when she received a call from R1's family and asked about his Social Security check for the month of December 2022. V1 (Asst…

    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 · D2023-11-15 · 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 interview and record review the facility failed to immediately investigate an injury of unknown origin for 1 of 3 residents (R1) reviewed for abuse in the sample of 7. The findings include: R1's face sheet printed on 11/9/23 showed diagnosis including but not limited to cerebrovascular disease, ataxia (muscle movement impairment), aphasia (speech impairment), and vascular dementia without behavioral disturbance. R1's facility assessment dated [DATE] showed severe cognitive impairment. The assessment showed total staff assistance required for bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene. The same assessment showed R1 is always incontinent of urine and bowel. R1's care plan showed a focus area related to incontinence. Interventions included check pads or briefs every two hours and report any red areas to the nurse. R1's progress note dated 11/7/23 (Tuesday) showed around 6:30 AM a CNA reported a bruise to R1's lower abdomen/pubic area. The writer checked on R1 and was…

    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 · Dcited before2023-11-15 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to implement neurological assessments following an unwitnessed fall. This applies to 1 of 5 residents (R2) reviewed for falls in the sample of 7. The findings include: R2's admission Record (Face Sheet) showed an original admission date of 8/29/23. The Face Sheet showed diagnoses to include traumatic subarachnoid hemorrhage (a bleed in the space surrounding the brain due to a traumatic event); injuries due to a motor vehicle accident; schizoaffective disorder; and altered mental status. R2's 9/5/23 admission Minimum Data Set (MDS) showed he had moderate cognitive impairment with a brief interview for mental status score of 12 out of 15. The MDS showed he required limited assistance of one person for walking in his room. The MDS showed he used a walker and wheelchair for mobility. On 11/14/23 at 11:13 AM, V14 Speech Therapist stated R2 and the room next to his share a bathroom. V14 said she was working in the adjoining room when she heard a bang and R2 had opened the bathroom door with his back as he fell to the ground. V14…

    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 before2023-07-27 · 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 ensure the sanitizing buckets used to sanitize the food preparation areas, had the correct sanitizing concentration in them, and failed to ensure the scoops were clean and not stored directly in the food products, inside the storage bins. This has the potential to affect all of the residents in the facility. The findings include: The Resident Census and Condition form dated 7/25/23 showed 80 residents resided in the facility. The same form showed 3 of these residents received tube feedings. The facility's Diet Type Report, printed by the facility on 7/27/23, showed 1 of the 3 residents (R73) receiving tube feedings, also receives pleasure feedings. On 7/25/210:02 AM, a scoop for the thickener was sitting on top of the storage bin container for the thickener used in food preparation. The scoop was upside down. There were multiple visible areas on the scoop with a white substance. The bin containing the dry oatmeal had the scoop inside the bin, sitting in the dry oatmeal product. On 7/25/23 at 10:23 AM, V16…

    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 before2023-07-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents on mechanically altered diets with swallowing problems were placed in an upright position for eating, and failed to ensure preventative measures for falls were in place for 5 of 6 residents (R35, R1, R13, R17, R46) reviewed for safety and supervision in the sample of 22. The findings include: 1. On 7/25/23 at 12:24 PM, R35 was sitting in a reclining wheelchair with a tray table in front of her. R35 was laying at a 45-degree angle while feeding herself a pureed diet. R35 had nectar thick liquids on her tray. R35's meal ticket next to her plate showed she has a general pureed diet with nectar thick liquids. Her meal ticket stated General pureed diet with nectar thick liquids. R35 had yogurt, applesauce, pureed bread, pureed stuffing, pureed pork, mashed cabbage, and gravy for her meal. On 7/26/23 at 12:03 PM, R35 was sitting in a reclining wheelchair at a 45-degree angle. R35 had a pureed diet with nectar thick liquids in…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-27 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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 release a resident's physical restraints per physician's orders for 1 of 4 residents (R76) reviewed for physical restraints in the sample of 22. The findings include: R76's electronic face sheet printed on 7/27/23 showed R76 has diagnoses including but not limited to psychosis, epilepsy, severe intellectual disabilities, and autistic disorder. R76's facility assessment dated [DATE] showed R76 has severe cognitive impairment and uses limb restraints daily. R76's care plan dated 10/3/22 showed, Restraints: bilateral hand mittens on at all times. Potential for adverse effects from use of right-hand mitten to prevent patient from scratching or hitting self. Bilateral hand mittens on continuous .off for care, activities, and meals. R76's physician's orders showed, 7/1/22 Monitor mittens when applied and release every 2 hours. 10/3/22 hand mittens continuous to prevent patient from scratching or hitting self, off during care, meals, and release…

    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 · Dcited before2023-07-27 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to keep a contracted residents nails trimmed for one of two residents reviewed for activities of daily living in the sample of 22. The findings include: On 7/25/23 at 10:36 AM, R4 was laying on his back in bed with his left arm up to his chest. R4's hands were contracted; his nails were long and cutting into the palms of his hands. On 7/26/23 at 10:55 AM, R4 was sitting up in bed, hands contracted, nails very long and digging into skin. R4's right thumb nail was jagged. On 7/26/23 at 11:00 AM, V8 (Restorative Aide/Certified Nursing Assistant) went to R4's room and looked at his hands and nails. V8 stated R4's nails were too long. On 7/27/23 at 9:30 AM, V2 (Director of Nursing/DON) stated a resident's fingernails are trimmed at shower time. V2 stated residents receive showers twice a week and CNAs are responsible for cutting nails at that time and as needed. The MDS (Minimum Data Set) dated 5/22/23 for R4 showed moderate cognitive impairment, total dependence on staff for bed mobility, transfers, dressing, toilet…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-27 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement a physician's order to monitor weights for a resident with edema (R17), failed to deliver a meal tray and monitor a resident on a mechanically altered diet for 1 resident (R30). These failures apply to 2 of 3 residents reviewed for quality of care in the sample of 22. The findings include: 1) R17's electronic face sheet printed on 7/27/23 showed R17 has diagnoses including but not limited to chronic obstructive pulmonary disease, type 2 diabetes, history of falls, dementia without behaviors, schizophrenia, dysphagia, and hypertension. R17's facility assessment dated [DATE] showed R17 has moderate cognitive impairment. R17's physician note dated 6/27/23 showed, Bilateral lower extremity edema .monitor weights weekly, update if weight gain of 2 lbs. in a day or 5 lbs. in a week . R17's physician note dated 7/24/23 showed, Extremities: Edema +2 right lower extremity, +1 left lower extremity .monitor weights weekly, update physician…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-27 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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 wear gloves when providing incontinence care and handling soiled linens for 1 of 4 residents (R46) reviewed for infection control in the sample of 22. The findings include: R46's electronic face sheet printed on 7/27/23 showed R46 has diagnoses including but not limited to arthropathy, pneumonia, history of falling, dementia, and chronic obstructive pulmonary disease. R46's facility assessment showed R46 has moderate cognitive impairment. On 7/26/23 at 9:32AM, V12 (Certified Nursing Assistant/CNA) provided incontinence care to R46. R46 had an incontinence brief on with urine and feces inside of it. V12 cleansed R46's perineal area, removed her gloves, and then provided bed mobility to turn R46 while grabbing her bare buttocks with her ungloved hands. V12 then took each of R46's thighs and spread them apart next to her vaginal area to apply a clean incontinence brief without gloves on. V12 did not perform hand hygiene before applying clean lines and repositioning R46's head with her bare hands. V12 then…

    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

“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

$8,328 in federal fines across 1 penalty. 1 Medicare payment denial on record.

  • $8,328 — penalty dated 2023-11-15
  • Medicare payment denial — starting 2023-12-23 for 11 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleSince
TOPPER, AARONIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2007
JAIN, SACHINIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/03/2022

CMS files one row per role, so the 5 rows in the source record cover these 2 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.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$8.2M
Net patient revenuemost recent cost report
-11.0%
Operating marginrevenue minus expenses
$1.1M
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 77%Medicare 11%Other / private 12%

About 77% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.1M paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$298per resident / day
operating cost
$9,057per month
≈ monthly operating cost
$268per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in IL

Paying with Medicaid

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.

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 145621. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-21, 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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