Bella Terra Wheeling

Location & what’s nearby

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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

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.

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.

46.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 157 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 64.0% 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 86 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 19% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 26% 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.

Staffing

How full it usually is: this home is certified for 215 beds and averages 169.8 residents a day — about 79% occupied, or roughly 45 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 3.23 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.77 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.89 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.16 hrs/resident/day on weekends vs 3.26 on weekdays — 3% thinner on weekends. RN hours go from 0.75 to 0.82 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 36% is about the same as the national median of 45%.

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

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

22 citations, most serious first. The 14 most serious are shown; the remaining 8 are one tap away and print in full.

• Actual harm · Gcited before2025-01-13 · 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 the interview and record review, the facility failed to provide appropriate assistive devices and staff supervision while walking to two cognitively impaired, high-risk falls residents (R1, R2) out of 3 residents reviewed for incidents/accidents. These failures resulted in R1 bumping R1's nose on the hallway countertop and sustained a nasal fracture. Findings Include: R1's clinical records show an initial admission date of 11/30/22 with included diagnoses but not limited to Unspecified Dementia Without Behavioral Disturbance, Unspecified Psychosis, History of Falling, and Altered Mental Status. R1's Minimum Data Set (MDS) dated [DATE] shows R1 has severe cognitive impairment and requires supervision or touching assistance with walking. R1's fall risk evaluation dated 9/09/24 shows R1 is at high risk for falls. This fall risk evaluation also shows R1 has unsteady gait, has memory problem, and is able to walk with assistance and/or assistive device. R1's restorative mobility evaluation dated 9/09/24 shows…

  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 before2024-08-08 · 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 observations, interviews and record review, the facility failed to ensure a resident's right to be free from physical harm and mental abuse for 1 (R1) of 4 residents reviewed for abuse in the sample of 5. This failure resulted in R1 being verbally and physically assaulted by staff causing bruising and lacerations during an unprovoked altercation. Findings include: R1 is a [AGE] year old female admitted to the facility on [DATE] with diagnosis including but not limited to Dementia; Suicidal Ideations; Anxiety Disorder; Major Depressive Disorder; Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris; Chronic Pain Syndrome; Chronic Obstructive Pulmonary Disease; Hypertension; and Epilepsy. According to R1's MDS (Minimum Data Set) assessment dated [DATE], under section C, R1 has BIMS (Brief Interview of Mental Status) score of 15 indicating intact cognition. According to R1's MDS (Minimum Data Set) assessment dated [DATE], under section E, R1 had not shown any psychotic behaviors.…

  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
• Actual harm · Gcited before2024-08-08 · 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 interviews and record review, the facility failed to keep a severely cognitively impaired resident at high risk for falls and with history of falls from a mechanical fall while providing routine ADLs (activities of daily living care) and failed to follow fall prevention protocols for 1 (R2) of 3 residents reviewed for accidents/hazards in the sample of 5. This failure resulted in R2's transfer to the hospital Emergency Department and diagnosis of comminuted displaced intertrochanteric right femur fracture. Findings include: R2 is a [AGE] year old female admitted to the facility on [DATE] with diagnosis including but not limited to Displaced Intertrochanteric Fracture of Right Femur; Epilepsy; Restlessness and Agitation; Abnormal Posture; Degenerative Disease of Nervous System; Delusional Disorders; Osteoarthritis; Osteophyte Right and Left Hip; and Progressive Vascular Leukoencephalopathy. According to R2's MDS (Minimum Data Set) assessment dated [DATE], under section C, R2 has memory problems 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
• Actual harm · Gcited before2023-11-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to identify supervision needs and implement measures to reduce fall risk for a confused resident at risk for falls, failed to implement plan of care interventions and falls policy to prevent resident's fall and injury. This failure affects 1 (R1) of 3 residents reviewed for accidents/incidents in the sample and resulted in R1 being emergently transferred to the hospital for hip fracture with surgical intervention. Findings include: R1 is a [AGE] year old male admitted to the facility on [DATE] with diagnosis including but not limited to Retention of Urine, Unspecified; Polyosteoarthristis, Unspecified; Atrioventricular Block, Second Degree; Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, and Anxiety; Altered Mental Status, Unspecified; Unspecified Symptoms and Signs Involving Cognitive Function and Awareness; Unspecified Hearing Loss; Adult Failure to Thrive; and Fracture of Unspecified Part of Neck of Left Femur,…

  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 before2025-06-22 · 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 interviews and record review, the facility failed to follow its abuse policy to ensure one resident (R1) remained free from physical abuse by another resident (R2) in a sample of three reviewed. This failure resulted in R1 sustaining lacerations to the forehead and swelling to the left eye. findings include: R1 is an [AGE] year-old, originally admitted on [DATE] with medical diagnoses that include and are not limited to: Parkinson's Disease, senile degeneration of the brain, and Alzheimer's disease. Minimum data set (MDS) dated [DATE] reads: Cognitive Skills for daily decision making: severely impaired. Per abuse, neglect, exploitation, and trauma assessments dated: 10-31-2019 and 3-7-2025, read: high risk for abuse: R1 has a diagnosis of delusional disorder, gets easily annoyed with others, especially during care, and will push staff and yell. R2 is a [AGE] year-old, originally admitted on [DATE] with medical diagnoses that include and are not limited to: dementia unspecified severity, with other…

  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 · D2025-01-13 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications were administered as scheduled per physician orders to 3 (R3, R4, R5) out of 3 residents reviewed for medication administration. Findings Include: On 1/12/25 at 9:13 AM, I interviewed R3. R3 stated that yesterday (1/11/25), R3 received [R3's] 9:00 AM medications closed to lunch time. R3 stated they were two hours late. On 1/12/25 at 10:26 AM, the Surveyor observed V8 (Agency Registered Nurse) enter R4's room and administer two insulin injections and medication pills to R1. The Surveyor asked what [V8] had just given to R4 and stated that those were R4's 9:00 AM medications. On 1/12/25 at 10:31 AM, R4 stated that sometimes on weekends, [R4] would get [R4's] medications late, sometimes one hour to two hours late. On 1/12/25 at 10:37 AM, R5 stated that [R5] does not pay attention with the time [R5] gets [R5's] medications and is not sure if [R5's] getting them on time or not. On 1/12/25 at 10:38 AM, V11 (Agency Registered…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-10-25 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility failed to notify the residents Power of Attorney (POA) of an abnormal labororatory results and change in medication/treatment to 1 of 3 residents (R1) reviewed of notification of change in the sample of 3. The findings include: On 10/25/24 at 12:27 PM, V7 (R1's POA) said she was not notified when her mom (R1) had an abnormal lab result of low potassium level and R1 was put on Potassium medications. V7 said R1 has heart failure and a change in her potassium level is significant. V7 said she was R1's POA and she should have been notified of new orders or changes in R1's medications or condition. A progress note dated 10/22/24 by V6 (Registered Nurse) showed R1 had a low potassium level (2.2) and was started on Potassium Chloride 40 meq tablet. The progress notes did not show that V7 (R1's POA) was notified. On 10/25/24 at 3:15 PM, V6 (RN) said he was not able to inform V7 R1's POA of the abnormal potassium level and R1 being started on Potassium tablets. V6 said if he did, he would have documented the notification. On 10/25/24 at 3PM,…

  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 · Ecited before2024-04-26 · tag F0812 — failed to store, cook, and serve food safely — pattern
  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 food containers are stored off the floor and ensure staff are employing hygienic practices during food handling in the dining room. This deficiency has the potential to affect all 165 residents receiving food from the kitchen. Findings include: On 4/23/2024 at 11:05 AM, observed 6 cans of fruit cocktail on the floor in the dry storage room during the initial tour. On 4/23/2024 at 11:05 AM, V12 (Cook) stated those cans should not be on the floor. On 4/23/2024 at 01:00 PM, V1 (Administrator) stated cans of food should be stored on the shelves when delivered. It should be off the floor. On 4/23/2024 at 12:23 PM, observed V13 (Dietary Aide) during lunch in the dining room touched and adjusted her eyeglasses with gloved hands then proceeded to continue preparing food without performing hand hygiene and changing gloves. On 4/23/2024 at 12:24 PM, V13 said I should have changed gloves before continuing to prepare food. On 4/24/2025 at 10:31 AM, V3 (Assistant Director of Nursing/Infection Control) stated V13…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-04-26 · 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 implement appropriate transmission-based precaution and to provide the necessary personal protective equipment (PPE) supplies readily accessible for use by staff and visitors for 3 of 3 residents (R153, R47, R131) reviewed for transmission-based precaution in a sample of 37. Findings include: On 4/23/2024 at 12:05 PM, R153 identified positive COVID 19 and on isolation. Observed isolation signage outside room as Contact Precaution, no other sign identified. On 4/23/2024 at 12:05 PM, V11 (License Practical Nurse - LPN) stated R153 is on isolation for COVID 19 and should have a signage of Contact and Droplet Precaution. On 4/23/2024 at 01:00 PM, V2 (Director of Nursing - DON) said R153 should be Droplet Precaution. On 4/24/2024 at 10:31 AM, V3 (Assistant Director of Nursing/Infection Control) stated R153 should have a signage outside the room of Contact and Droplet Precaution. On 4/23/2024 at 11:45 AM, R47 and R131 on Contact Precaution with Personal Protective Equipment (PPE) bin set-up outside the room. PPE bin…

  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 · D2024-04-26 · 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 interviews and record reviews, the facility failed to follow its intravenous therapy policy and accurately assess and monitor resident's signs/symptoms/change of condition, which resulte in delay of care and resulted in MRSA spread causing decline in resident's health, with infection to knee and MRSA pneumonia for one resident's (R422) PICC (peripherally inserted central catheter) out of three reviewed for change in condition in a sample of 37. This failure resulted in R422 developing chills, elevated white blood cell count, and malaise. R422 was transported to the hospital and diagnosed with MRSA infection of PICC line causing MRSA infection of right knee and MRSA pneumonia. Findings include: On 4/26/24 at 8:56 AM, V14 RN (Registered Nurse) stated that PICC (peripherally inserted central catheters) dressing is changed weekly. V14 stated that all the needed supplies are in kit. V14 stated that when you record arm circumference and external catheter length, the previous documented result will appear so that you can compare previous result with current result. V14 stated that…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2023-09-23 · 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 interview and record review, the facility failed to have effective interventions in place to keep residents free from physical abuse. This failure applied to two (R4 and R5) of three residents reviewed for abuse. Findings include: R4 and R5 are the subjects of this incident investigation. R4 is a [AGE] year-old resident admitted on [DATE]. R4 has medical diagnoses that include: unspecified psychosis, Alzheimer's disease, anxiety, and unspecified dementia with other behavioral disturbances. R4's abuse assessment upon admission, dated 7/20/23, documents that R4 is at risk of abuse. Narrative section documents that R4 yells at staff and tell them to drop dead and poke her finger at them; she also spits. R4's current care plan includes a focus with date initiated 7/20/23 and reads: (R4) exhibits agitation and calls out and has hit the staff as well as bit another resident; Behavior Focus includes (R4) exhibits confusion r/t her Dementia. She has been spitting on the floor and at staff. Per son, she does…

  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 before2023-08-13 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop 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 observation, interview and record review, the facility failed to develop and implement a comprehensive fall prevention plan of care for 1 of 3 residents (R1) reviewed for fall care planning in the sample. Findings include: R1 is a [AGE] year old with severe cognitive impairment and diagnosis of dementia, major depressive disorder, atrial fibrillation and hypertension. Care Plan dated 8/9/2022 shows in part, (R1) is at risk for falls related to: Current medication use antidepressants and antipsychotics, Disease process (Polyosteoarthritis, UTI, A-Fib., HTN, Depressive disorder, Dementia). R1 utilizes a wheelchair as primary means for locomotion. R1 will be free of falls through next review date. Ensure R1 is sitting in the center of her wheelchair, offer and assist to take naps in her bedroom in between meals. Keep call light within reach when in bedroom or bathroom. Side rails to aid in bed mobility and transfers. Use of assistive device during ambulation to prevent falls. There were no interventions…

  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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-08-13 · tag F0658 — failed to meet professional standards of care — isolated
  Ensure services provided by the nursing facility meet professional standards of quality.
  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 care in accordance with professional standards of quality by failing to prevent falls with significant injuries, and failed to train facility nursing staff on fall preventions and provide implementation of assistive and/or preventative devices to prevent falls. This failure affected 1 of 3 residents (R1) reviewed for falls in the sample. Findings include: R1 is a [AGE] year old with severe cognitive impairment and diagnosis of dementia, major depressive disorder, atrial fibrillation and hypertension. Care Plan dated 8/9/2022 shows in part, (R1) is at risk for falls related to: Current medication use antidepressants and antipsychotics, Disease process (Polyosteoarthritis, UTI, A-Fib., HTN, Depressive disorder, Dementia). R1 utilizes a wheelchair as primary means for locomotion. R1 will be free of falls through next review date. Ensure R1 is sitting in the center of her wheelchair, offer and assist to take naps in her bedroom 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2023-08-13 · 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 provide adequate supervision for 1 of 3 (R1) residents with severe cognitive impairment and fall risk reviewed for accident/hazards in the sample; failed to provide an environment that was free of accidental hazards; and failed to follow R1's plan of care to prevent accidental falls. Findings include: On 8/11/23 at 10:22 AM, R1 was observed in the dining area slumped over and asleep in a wheelchair. R1 displayed facial injuries of a swollen lip with dried blood on the right side of her mouth and a right eye that appeared to be swollen shut. R1 was slumped over to the same side she had recently fallen on and there were no preventative devices observed such as a chair alarm nor wedge cushion to prevent R1 from further falls. V5 (Memory Care Manager) stated, This is her usual place in the dining room and it was where she was seated when she fell over last week. Surveyor asked what the facility did to prevent the fall from happening to begin…

  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

“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.

Fines & penalties

$28,054 in federal fines across 2 penalties.

• $15,015 — penalty dated 2025-01-13
• $13,039 — penalty dated 2023-11-15

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.

Part of a chain

This home belongs to LEGACY HEALTHCARE — 89 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 19 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

7 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

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.

About 78% 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 $2.2M paid to related parties — landlords or management companies under common ownership — equal to about 11% 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.

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

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