EverVella of White Hall
620 West Bridgeport, White Hall, IL 62092 · For profit - Limited Liability company · 119 certified beds · (217) 374-2144 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0600), cited Oct 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (64%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 28.5% | 13.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.0% | 6.3% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.9% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 20.9% | 54.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.7% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 22.4% | 14.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 32.5% | 18.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.4% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 18.0% | 20.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 21.6% | 21.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 98.3% | 63.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 24.4% | 26.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 9.7% | 13.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.12 | 2.02 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.63 | 2.22 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
53.2% 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 108 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 57.1% 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 28 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 21% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 53.2%CMS range 45.0–61.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.9%CMS range 8.2–15.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 57.1% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 60.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 42.9% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 75.6% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.2% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.7%CMS range 4.1–11.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.19 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 119 beds and averages 103.5 residents a day — about 87% occupied, or roughly 16 beds typically open. It runs fairly full. 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 2.86 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.30 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.87 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 2.56 hrs/resident/day on weekends vs 2.99 on weekdays — 14% thinner on weekends. RN hours go from 0.32 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 64% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
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.
30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · Gcited before2025-08-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to investigate and provide progressive interventions to prevent falls for one of 10 residents (R34) reviewed for accidents and supervision in the sample of 62. These failures resulted in R34 sustaining a laceration to the face requiring 5 sutures. Findings include: R34's Face sheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, dementia, muscle weakness, difficulty in walking, and need for assistance with personal care. R34's MDS dated [DATE] documented she was rarely/never understood, had a memory problem and her cognitive skills for daily decision-making regarding tasks of daily life were severely impaired. R34's Fall Risk assessment dated [DATE] and 6/12/25 documented she was a high fall risk and to implement high fall risk fall prevention interventions. R34's current Care plan requested and provided by the facility documented she had an actual fall with no injury initiated 11/22/24 with interventions as follow: on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-26 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide fluids on the night shift for 2 of 9 residents (R6, and R9) reviewed for hydration in the sample of 9. Findings include:1 On 2/23/2026 at 8:03AM R6 stated she does not always have water at bedside. R6 stated from 6-7pm until breakfast has nothing to drink.R6's Minimum Data Set (MDS) dated [DATE] documents R6 is cognitively intact.2 On 2/24/2026 at10:10 am R9 stated water is not passed on the night shift.R9's MDS dated [DATE] documents R9 is cognitively intact. The facility resident council minutes dated 2/2026 documents water not being passed on the night shift. On 2/25/2026 at 9:15AM, V1, Director of Nursing (DON) stated she would expect staff to be passing water/fluids on the night shift. The facility policy hydration, dated 2023 documents the facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. The policy documents…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-21 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
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 maintain secure medical records for 1 of 4 (R11) reviewed for privacy / confidentiality of records in the sample of 13.Findings include:R11's Face Sheet, print date of 11/20/25, documents R11 was admitted on [DATE] with diagnosis of Dementia. R11's Minimum Data Set, dated [DATE], documents R11 is severely cognitively impaired. R11's Nurses Note, dated 11/16/25, documents R11 passed away under hospice care. On 11/20/25 at 8:10 AM, V33, Licensed Practical Nurse, (LPN), stated I was present when V34 LPN was upset because the narcotic count sheet for R11 was wrong. V34 went through and figured out that it was a math error not an actual drug divergence. V34 took it to V2, Director of Nurses, and wanted him to fix it. V34 was upset because V2 wouldn't fix it immediately. V2 told her he had to do an investigation into it. V34 told me she took a photo on her phone of the narcotic count sheet, a printed copy of the Medication Administration Record (MAR), and a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-21 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to assist 1 of 4 residents (R3) reviewed for feeding assistance in the sample of 13. Findings include:R3's Face Sheet, print date of 11/20/25, documents R3 was admitted on [DATE] with diagnoses of Parkinson's Disease with Dyskinesia and Major Depressive Disorder with severe psychotic symptoms. R3's Minimum Data Set, dated [DATE], documents R3 has moderate cognitive impairment, requires set up clean up assistance for dining, requires supervision touch assist for toileting, partial to moderate assist with hygiene, sitting to standing position change, toilet transfer, and is occasionally incontinent of urine. On 11/16/25 at 7:34 AM R3 is sitting in the dining room. R3 has a plate of scrambled eggs, a muffin, a bowl of fruit loops, both juice and water, a Coke can, and both white and chocolate milk. R3 is attempting to grab and use her spoon. R3 is unable to manipulate the spoon. R3's left arm and hand are extremely shaky. At 7:42 AM, R3's plate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-08-28 · tag F0761 — failed to label and store drugs safely — widespreadEnsure 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 Interview, Observation, and Record Review, the facility failed to dispose of expired medications, properly label medications, and to keep food items out of the medication refrigerator reviewed for medication storage and labeling in the sample of 62. This failure had the potential to affect all residents in the facility. The Findings Include: 1. On 8/26/25 at 2:45 PM, the Rehab Medication Room was assessed with the following findings: Tuberculin (TB) Vial 1 ML (milliliter) had a sticker on the box for when it was opened on 7/15/25, the sticker documents Do Not Use 30 days past above date. Vitamin B-12 100 MCG (micrograms), 100-tab bottle expired on 7/2025. Docusate 100 MG (milligram), 1000-tab bottle expired on 7/2025. On 8/26/25 at 3:05 PM, V25, Registered Nurse (RN)/Nurse Manager/Infection Preventionist (IP), stated The TB vial in the Rehab Med Room is used mainly for all the residents. The TB stored in the med room up front, is used for all of the residents and the staff. On 8/27/25 at 1:00PM, V2, Director of Nursing (DON), stated I would expect the nurses to properly…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-08-28 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to perform hand hygiene, wear gloves, and wear Personal Protective Equipment for 4 of 20 residents (R2, R50, R61, R104) reviewed for infection control in the sample of 62.Findings include: 1.On 8/26/25 at 9:06 AM V29, Certified Nurse Aide, (CNA) and V28 CNA entered R50's room to transfer R50 to bed and check for incontinence. V28 did the incontinent care correctly but during the incontinence care, V28 changed gloves twice without hand hygiene in between. On 8/27/25 at 3:20 PM, V2, Director of Nurses, stated hands should be washed between glove changes. R50's admission Record, print date of 8/27/25, documents R50 was admitted on [DATE] and has a diagnosis of Dementia. 2. On 8/25/205 at 11:45 AM during lunch V4, CNA removed chocolate chip cookie from bag with bare hands and placed on table beside R104's plate. V4 did not sanitize hands prior to handling food or wear gloves. R104's face sheet documents R104 was admitted to the facility on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-08-28 · tag F0881 — failed to use antibiotics responsibly — patternImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the failed review a urinalysis, complete a McGreer evaluation before notifying the doctor and starting antibiotics for 4 of 9 residents (R5, R14, R57, R61) reviewed for antibiotic stewardship in the sample of 62.Findings include:1. R57's admission record, print date of 8/27/25, documents R67 was admitted on [DATE] and has diagnoses of Dementia and a history of a stroke. R57's Nurses Note, dated 8/3/25, documents, Received UA (urinalysis) results, sent to (V37, Medical Director), awaiting culture. Received order for Augmentin 875mg (milligram) BID (twice a day) for 7 days. Orders put in. POA (Power of Attorney) notified. R57's Urinalysis with culture if indicated, resulted date of 8/4/25, document, Organism: (GNR) Gram Negative Rod, no sensitivity will be done. Growth: <10,000 cfu (colony forming unit)/ml (milliliter). R57's Medication Administration Record, August 2025, documents R57 received 16 doses of Amoxicillin-Pot Clavulanate Tablet 875-125 MG from 8/3/25 through…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-28 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations and record reviews the facility failed to provide dignity during meals for 2 out of 2 residents, (R49, R96); reviewed for resident rights in a sample of 62.Findings include: 1. R96's admission Record, dated 8/27/25, documents R96 was admitted to the facility on [DATE] with diagnosis of Dementia, Dysphasia, Phobic Anxiety disorders, Seizures, Type 2 Diabetic Mellitus (DM), and Congested Heart Failure (CHF). R96's Care Plan, dated 7/15/25, documents R96 is at increased nutritional risk related to her therapeutic diet, mechanically altered diet nectar (mildly) thickened liquids and Diagnosis of Type 2 DM, Dementia, history of dehydration. resident utilizes adaptive feeding equipment with meals. Interventions: assist with tray set up as needed: opening containers, etc. R96's MDS, dated [DATE], documents R96 has a severe cognitive impairment and requires set-up/clean-up assist for eating. 2. R49's admission Record, dated 8/27/25, documents R49 was admitted to the facility on [DATE]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-28 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Interview, Observation, and Record Review, the facility failed to follow through on Pharmacist's recommendations, including notifying the physician for medication review for possible changes to antipsychotic, and antianxiety medications for 3 of 5 residents (R1, R8, R9) reviewed for chemical restraints in the sample of 62.The Findings Include:1. R1's admission Record, dated 8/27/25, documents R1 was admitted to the facility on [DATE] with Diagnosis of Acute Respiratory Failure, Atrial Fibrillation (A-Fib), Chronic Kidney Disease (CKD), Congestive Heart Failure (CHF), Osteoarthritis, Obesity, Anemia, Generalized Anxiety Disorder, and Major Depressive Disorder.R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact. R1's Physician Order (PO), dated 6/30/25, documents Escitalopram Oxalate Oral Tablet 5 MG Give 1 tablet by mouth in the morning related to Major Depressive Disorder. R1's PO, dated 6/25/25, documents Memantine HCl Oral Tablet 5 MG (milligram), give 1 tablet by mouth two…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-28 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to document limited range of motion for 2 of 20 residents (R23, R61) reviewed for Minimum Data Set accuracy in the sample of 62.Findings include: 1 R23's admission record, print date of 8/27/25, documents R23 was admitted on [DATE] and has a diagnosis of Cerebral Palsy. R23's Minimum Data Set (MDS), dated [DATE] documents that R23 is cognitively intact and has no limited range of motion. On 8/26/25 at 12:30 PM, R23 stated that he does not get exercises on his arm or hand. R23 stated he has limited movement in his left arm and hand. On 8/26/25 at 12:37 PM, V2, Director of Nurses, stated that he agrees R23 has limited range of motion in both hands. On 8/27/25 at 1:44 PM, V33, Licensed Practical Nurse (LPN)/MDS, stated, I have only been here for a month. I have looked at R23 and I agree that his MDS should indicate that he has limited range of motion. Once the MDS is triggered for limited range of motion it then generates a care plan for range…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-28 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to initiate a Care Plan for 2 of 20 residents (R23, R61) reviewed for Care Plans in the sample of 62.Findings include: 1 R23's admission record, print date of 8/27/25, documents R23 was admitted on [DATE] and has a diagnosis of Cerebral Palsy. R23's Minimum Data Set, dated [DATE] documents that R23 is cognitively intact and has no limited range of motion. On 08/26/2025 at 12:44 PM, R23's current electronic Care Plan failed to document any restorative programing or limited range of motion. On 8/26/25 at 12:30 PM, R23 stated that he does not get exercises on his arm or hand. R23 stated he has limited movement in his left arm. On 8/26/25 at 12:30 PM, R23 attempted to open his left hand. R23 has 3 fingers that are curled up into the palm of his hand. R23's right hand has 2 contracted fingers. On 8/26/25 at 12;37 PM, V2, Director of Nurses, further stated that he agrees R23 has limited range of motion in both arms. On 8/27/25 at 1:44 PM, V33,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 19 citations
- Potential for harm · Dcited before2025-08-28 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observation and record reviews the facility failed to provide feeding assistance for 1 out of 1 residents (R34); reviewed for Quality of Life in a sample of 62. Findings include:R34's Face sheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, dementia, vitamin deficiency, and abnormal weight loss.R34's Minimum Data Set (MDS) dated [DATE] documented she was rarely/never understood, had a memory problem, and required partial/moderate assistance from staff for eating. R34's Care Plan revised on 11/6/24 documented she was at increased nutritional risk; R34 is assisted at meals and offered encouragement/cueing as needed. Interventions added 11/6/24 documented for staff to offer finger foods also. R34's Progress note dated 8/22/25 at 1:59 PM, documented she is dependent on staff to meet ADLs (activities of daily living) and remains on hospice care services. On 8/25/25 at 11:18 AM R34 was sitting in an upright positioned recliner took her fork and stabbed it into…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-28 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide 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 interview, observation, and record review, the facility failed to provide range of motion for 2 of 2 residents (R23, R61) reviewed for contractures in the sample of 62. Findings include: R23's admission record, print date of 8/27/25, documents R23 was admitted on [DATE] and has a diagnosis of Cerebral Palsy. R23's Minimum Data Set (MDS), dated [DATE] documents that R23 is cognitively intact. On 08/26/2025 at 12:44 PM, R23's Care Plan failed to document any restorative programing or limited range of motion. R23's Occupational Therapy Discharge summary, dated [DATE], documents, Discharge recommendations. Functional Maintenance Program Established / Trained = Range of Motion Program. Range of Motion Program Established / Trained: Therapist instructed staff in PROM program of bilateral shoulder flexion and abduction and ring and little digit extension up to 7x per week and for 2 sets of 10 reps (repetitions). On 8/26/25 at 12:30 PM, R23 attempted to open his left hand. R23 has 3 fingers that are curled up…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-28 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Interview, Observation, and Record Review, the facility failed to follow through with the Pharmacist's Medication Regimen Review (MRR), including notifying the physician and obtaining any medication changes as ordered for 3 of 5 residents (R1, R8, R9) reviewed for resident's MRR in the sample of 62.The Findings Include: 1. R1's admission Record, dated 8/27/25, documents R1 was admitted to the facility on [DATE] with Diagnosis of Acute Respiratory Failure, Atrial Fibrillation (A-Fib), Chronic Kidney Disease (CKD), Congestive Heart Failure (CHF), Osteoarthritis, Obesity, Anemia, Generalized Anxiety Disorder, and Major Depressive Disorder.R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact. R1's Physician Order (PO), dated 6/30/25, documents Escitalopram Oxalate Oral Tablet 5 MG Give 1 tablet by mouth in the morning related to Major Depressive Disorder. R1's PO, dated 6/25/25, documents Memantine HCl Oral Tablet 5 MG (milligram), give 1 tablet by mouth two times a day related 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.
- Potential for harm · D2025-08-28 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
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 failed to notify the Physician to clarify the continued need for an antibiotic for 2 of 7 (R14, R57) reviewed for medications in the sample of 62.Findings include:1. R57's admission record, print date of 8/27/25, documents R67 was admitted on [DATE] and has diagnoses of Dementia and a history of a stroke. R57's Nurses Note, dated 8/3/25, documents, Received UA (urinalysis) results, sent to (V37, Medical Director), awaiting culture. Received order for Augmentin 875mg (milligram) BID (twice a day) for 7 days. Orders put in. POA (Power of Attorney) notified. R57's Urinalysis with culture if indicated, resulted date of 8/4/25, document, Organism: (GNR) Gram Negative Rod, no sensitivity will be done. Growth: <10,000 cfu (colony forming unit)/ml (milliliter). R57's Medication Administration Record, August 2025, documents R57 received 16 doses of Amoxicillin-Pot Clavulanate Tablet 875-125 MG from 8/3/25 through 8/11/25. On 08/27/2025 at 12:12 PM, V25, Registered Nurse /…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-31 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to coordinate services between the facility and resident's oncology provider for one of one resident (R3) reviewed for coordination of services to provide quality of care in the sample of 8. Findings include: R3's Care Plan, dated 10/10/2024, documents R3 is to have an individualized plan of care while at the facility. Staff to follow individualized plan of care to meet resident's needs. R3's Care Plan does not address her blood cancer or her seeing an oncologist, V8. R3's Report of Consultation, dated 6/24/24, documents Reason for Consultation: increase platelets. Findings: Increase platelets, splenomegaly, and weight loss. Diagnosis Increase platelets, probably ET (Essential Thrombocythemia). Recommendations: Add 2-3 cans of Boost or equivalent between meals, check Jak-2 mutation, continue ASA (aspirin). Testing.com website, documents the Jak2 Mutation test is used To help diagnose bone marrow disorders known as myeloproliferative neoplasms (MPNs) in which bone marrow produces too many or one or more types of blood cells.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-31 · tag F0773 — isolatedProvide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure the Oncologist and the Attending Physician were notified of a significant lab value for 1 of 8 residents (R3) reviewed for reporting of laboratory results in the sample of 8. Findings include: R3's Report of Consultation, dated 6/24/24, documents Reason for Consultation: increase platelets. Findings: Increase platelets, splenomegaly, and weight loss. Diagnosis Increase platelets, probably ET (Essential Thrombocythemia). Recommendations: Add 2-3 cans of Boost or equivalent between meals, check Jak-2 mutation, continue ASA (aspirin). R3's Lab Results, not dated, documents lab collected 7/2/2024 at 5:05 AM. Received 7/3/2024 at 3:50 AM. Reprinted 7/12/2024 10:30 PM. A date of 7/15/204 located at the bottom right corner with no context given. A stamp Scanned Date/Initials with unrecognizable date and initials. R3's Progress Note, dated 10/24/2024 at 1:57 PM, documents Progress Note Text: received call from (V8's, Oncology Physician) office inquiry if resident had [NAME] 2 lab drawn. Stated resident must have the lab…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-10-21 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to provide a Registered Nurse (RN) for a least 8 consecutive hours a day for 7 days a week. This failure has the potential to affect all 106 residents residing at the facility. Findings include: On 10/17/24 at 10:30 AM V19, Licensed Practical Nurse, stated that the day shift for nurses was from 6 AM to 6 PM and the Night shift runs from 6 PM to 6 AM. The facility's Staff Assignments, for August 2024, September 2024 and October 2024 were reviewed and on these dates, 8/22/2024, 8/28/2024, 8/29/2024, 9/1/2024, 9/5/2024, 9/12/2024, 9/18/2024, 9/20/2024, 9/23/2024, 9/26/2024, and 10/3/2024, failed to document that there was a RN working the floor for 8 consecutive hours on these days. On 10/17/24 at 01:05 PM, V1, Administrator, stated that they have a new scheduler and that she may not understand that a new day starts at 12 midnight and that she did not know if the facility has a policy but they follow the federal guidelines for RN coverage. The facility's Long-term Care facility Application for Medicare and Medicaid, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-10-21 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, observation, and record review, the facility failed to perform hand hygiene, discard of potentially contaminated medications to prevent cross contamination. The facility also failed to have a system in place to monitor and track infections in the facility for 6 of 10 (R12, R16, R46, R47, R54 and R83) residents reviewed for infection control in the sample of 68. Findings include: 1. On 10/16/24 at 8:26 AM, V12, Licensed Practical Nurse, (LPN), prepared medication to be administered to R83. V12 obtained Tylenol 2 tablets, 1 tablet Magnesium Oxide 400 milligram (mg), 4 capsules of Vitamin D3 50 micrograms, and placed them into a medication cup. V12 donned gloves without hand hygiene, retrieved the Tylenol and Magnesium Oxide tablets, and placed them into a pill pouch so they could be crushed. V12 crushed the tablets, mixed them with pudding, added the Vitamin D3 capsules, removed her gloves. V12 then entered R83's room and administered the medications to R83. 2. On 10/16/24 at 8:39 AM, V12 opened R16's morning medication pass packet which include: Metoprolol 50…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-10-21 · tag F0881 — failed to use antibiotics responsibly — patternImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to have an effective antibiotic stewardship program to monitor and track antibiotic use and infections in the facility for 4 of 4 (R12, R46, R47 and R54) residents reviewed for antibiotic stewardship/ Infection control in a sample of 68. Findings include: 1 . R12's physician order, dated 9/9/2024 documented, Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohyd Macro) Give 1 capsule by mouth two times a day related to URINARY TRACT INFECTION (UTI), SITE NOT SPECIFIED (N39.0) for 7 Days R12's physician order, dated 9/18/2024, documented, Keflex Oral Capsule 500 MG (Cephalexin) Give 1 capsule by mouth three times a day for UTI for 5 Days R12's physicians order, dated 9/24/2024, documented, Bactrim DS Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth two times a day for UTI for 5 Days. R12's McGreers Criteria, undated, documented, UTI criteria not met, for both antibiotic orders. R12's face sheet, dated 10/21/2024, documented a diagnosis of UTI. The facility's infection control log, dated 09/2024, did…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-21 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and record reviews the facility failed to evaluate, monitor, and prevent a physical altercation from occurring for 1 out of 2 residents, (R86), reviewed for abuse in a sample of 68. Findings include: R91 was admitted to the facility on [DATE] with diagnosis of, in part, sequelae of cerebral infarction, anxiety disorder and depression. R91's Minimal Data Set (MDS) dated [DATE], documented she was cognitively intact. R86 was admitted to the facility on [DATE] with diagnosis of, in part, unspecified dementia, unspecified severity and anxiety disorder. R86's MDS dated [DATE], documented she was severely cognitively impaired. On 10/15/2024, at 11:00 AM, R91 threw a brown liquid from her mug on R86 while sitting next to each other for lunch. R86 was sitting to the left of R91 and was visibly soaked by R91's beverage on her right arm and chest. R86 asked R91 why she would do that. R91 did not answer R86. R86 got up very quickly, shook her head in disapproval at R91 and then proceed 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.
- Potential for harm · D2024-10-21 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to administer medications as prescribed by the ordering Physician for 2 of 6 residents (R83,R103). This failure resulted in a medication error rate of 8%. Findings include: 1. On 10/16/24 at 8:15 AM, V12, Licensed Practical Nurse, (LPN), administered 1 Famotidine 10 milligram (mg) tablet to R103. R103's admission Record, print date of 10/21/24, documents that R103 was admitted on [DATE]. R103's Order Summary Report, dated 10/21/24, documents, Famotidine Oral Tablet 20 mg. give 1 tablet by mouth two times a day for GERD. (gastroesophageal reflux disease). Take 1 tablet PO (by mouth) BID (twice a day). 2. On 10/16/24 at 8:26 AM, V12 administered 4 Vitamin D3 2000IU (international units) 50 microgram (mcg) capsules to R83. R83's admission Record, print date of 10/21/24, documents that R83 was admitted on [DATE]. R83's Order Summary Report, dated 10/21/24, documents, Vitamin D3 Oral Tablet 25 mcg. Give 4 tablet by mouth one time a day related 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.
- Potential for harm · Ecited before2023-09-25 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect 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, observation, and record review, the facility failed to prevent resident to resident abuse for 5 of 22 residents (R17, R19, R33, R36, R208) reviewed for abuse in the sample of 58. Finding include: 1. R36's Face Sheet, print date of 9/19/23, documents R36 was admitted on [DATE], and has diagnoses of Dysphasia, Convulsions, Major Depression, and Dementia. R36's Care Plan, dated 1/22, documents, Mental wellness/Mood. I have Schizophrenia and Dementia; I wander a lot. I walk with my head down at times. I will wander into other peers' rooms as well. I can be resistive to cares. I like to grab a hold of caregivers or other peers. I do this out of fear that I'm going to fall or just not used to my environment. It continues, I will take food off of other peers' plates. Please redirect me to my own food. I put random items in my mouth especially at mealtimes. Please observe me for this and redirect me. R36's Care Plan, dated 1/22, documents, Safety Notes. I am a risk for falls. I have diagnosis of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-09-25 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 interview, observation, and record review, the facility failed to place a date on vial when a multi-use medication vial was opened, failed to maintain the medication refrigerator at the proper temperature, and failed to maintain a clean refrigerator and not store food in the medication refrigerator. This failure has the potential to affect 37 residents living in the Memory Unit. Findings include: On 9/20/23 at 10:00 AM, the Memory Unit Medication Room was observed. In the refrigerator there was 17 magic cup ice creams, the temperature was 32 degrees. The inside of the door had brown debris on the shelves, and there was an open undated bottle of Tubersol multi-dose vial. On 9/20/23 at 10:08 AM, V3, RN/Memory Unit Manager, stated food should not be kept in the medication refrigerator. They have been having trouble with the temperatures in that refrigerator, and any multi-use vial should be dated when opened. The policy Medication Storage, dated 1/15, documents, 18. Medications requiring refrigeration must be stored between 36 degrees F (Fahrenheit) and 46 degrees F in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-25 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, observation, and record review, the facility failed to report an allegation of abuse to the Administrator immediately for 2 residents (R18, R36) reviewed for abuse in the sample of 58. Findings include: On 9/19/23 at 10:50 AM, V16, Registered Nurse, stated, (R36) is inappropriate for the Memory Unit, because of his behaviors. He is physically aggressive and sexually inappropriate with staff. He really hasn't hurt any residents, but he will grab them. V16 stated, I am very worried for the residents, safety when I am not here, because of him. A night nurse (V17, Licensed Practical Nurse, (LPN)) has told me that she caught (R36) in the bed of his roommate (R18) rubbing his chest and stuff. (V17) told me it has happened a few times. I guess it started around May. V16 stated she did not know if V17 had reported the incident to the Administrator. V16 was questioned if she had reported it to the Administration, V16 stated, No, it was hearsay. I never saw (R36) do anything, sexually inappropriate to any resident. That's why. I was friends with (R18's) daughter and she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to complete injury report, investigate an injury, and implement identified interventions for one of five residents (R20) reviewed for falls in the sample of 58. Finding include: 1. R20's face sheet, dated 8/28/2022, documents a history of falling. R20's Minimum Data Set, (MDS), dated [DATE], documents R20 requires extensive assistance and one-person physical assistance for bed mobility and transfers. R20's fall risk assessment, dated 8/3/2023, documents a score of 75, with a score of 46 or greater being high risk for falls. R20's Resident incident report, dated 9/17/2023 at 5:30PM, documents, resident was found on floor next to bed and noted purple and red area to right side of head. No open area or drainage noted. The report documents, immediate actions taken fall and a mats was put in place. The facility does not provide any witness statements in regard to R20's fall on 9/17/2023. On 09/18/23 at 11:00AM, V33, R20's wife, was in the dining…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-09-06 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement broad based testing or contact tracing and implement infection control to prevent the spread of COVID infection. This has the potential to affect all 103 residents at the facility. Findings include: 1. On 8/29/2023 at 7:29 AM, V10 (Licensed Practical Nurse/LPN) was passing meds on the rapid recovery unit with Covid positive residents. V10's surgical mask was on under her nose. 2. On 8/30/2023 at 9:32AM, V2 (Interim Director of Nursing/DON) stated V19 (LPN) had called her on morning of August 9th, and told her she was positive for COVID. V2 stated V19 worked the rapid recovery unit on 8/6/2023. V19's time sheet documents V19 clocked in at 6:25AM and clocked out at 7:16PM on 8/5 and 8/6/2023, working 12 hours from 6:30am- 7:15 pm on both days V2 stated there was no contact tracing done at that time. V2 stated, If someone had symptoms we would test. (R1) was having psych issues and was sent to local hospital for evaluation 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.
- No harm found · Bcited before2025-08-28 · tag F0912 — patternProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide 80 square feet of floor space per resident in eight, 3-bed resident rooms for 19 of 19 residents (R3, R22, R24, R25, R27, R34, R36, R45, R51, R66, R71, R72, R76, R84, R89, R92, R95, R98, R99) reviewed for resident living space in the sample of 62 . Based on observation, interview, and record review, the facility failed to provide 80 square feet of floor space per resident in eight, 3-bed resident rooms for 19 of 19 residents (R3, R22, R24, R25, R27, R34, R36, R45, R51, R66, R71, R72, R76, R84, R89, R92, R95, R98, R99) reviewed for resident living space in the sample of 62 . Findings include: On 08/28/25 at 11:55 AM, the 8 three-bed resident rooms, (Rooms 51-58). Each room has three beds in it. Each room was licensed and available for three residents per room. According to historical measurement data, these eight rooms only provide 77 square feet per resident bed. The following residents reside in these rooms: R3, R22, R24, R25, R27, R34, R36, R45, R51, R66, R71, R72, R76, R84, R89, R92, R95, R98, 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.
- No harm found · Bcited before2024-10-21 · tag F0912 — patternProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, and record review, the facility failed to provide 80 square feet of floor space per resident in eight, 3-bed resident rooms for 23 of 23 residents (R2, R15, R20, R23, R28, R29, R33, R41, R44, R49, R52, R57, R60, R63, R74, R77, R79, R81, R87, R96, R98, R101, R365) reviewed for resident living space in the sample of 68. Findings include: On 10/16/2024 at 9:00AM, the 8 three-bed resident rooms, (Rooms 51-58) all had three residents residing in each of these rooms. Each room was licensed and available for three residents per room. According to historical measurement data, these eight rooms only provide 77 square feet per resident bed. The following residents reside in these rooms: R2, R15, R20, R23, R28, R29, R33, R41, R44, R49, R52, R57, R60, R63, R74, R77, R79, R81, R87, R96, R98, R101, R365. All eight of these three-bed resident rooms are Medicaid certified. On 10/17/2024 at 9:00AM V1, Administrator, stated We evaluate the compatibility and any behaviors a resident may be having, prior to putting them in a 3-person room.
- No harm found · Bcited before2023-09-25 · tag F0912 — patternProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, and record review, the facility failed to provide 80 square feet of floor space per resident in eight, 3-bed resident rooms for 24 of 24 residents (R6, R9, R12, R13, R17, R19, R26, R32, R33, R34, R35, R39, R48, R56, R58, R63, R68, R71, R73, R77, R85, R91, R93, R207) reviewed for resident living space in the sample of 58. Findings include: On 9/21/23 at 8:50AM, the 8 three-bed resident rooms, (Rooms 51-58) all had three residents residing in each of these rooms. Each room was licensed and available for three residents per room. According to historical measurement data, these eight rooms only provide 77 square feet per resident bed. The following residents reside in these rooms: R6, R9, R12, R13, R17, R19, R26, R32, R33, R34, R35, R39, R48, R56, R58, R63, R68, R71, R73, R77, R85, R91, R93, R207. All eight of these three-bed resident rooms are Medicaid certified. On 9/21/23 at 9:15AM, V1, Administrator, stated the residents are assessed prior to going into these rooms.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
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.
This home reported $1.5M 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. 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
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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145519. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-28, 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.