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Valley Hi Nursing Home

2406 Hartland Road, Woodstock, IL 60098 · Government - County · 128 certified beds · (815) 338-0312 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0602) — cited Feb 2023Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation$155,366 in federal fines2 Medicare payment denials
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0602), cited Feb 2023
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • 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
  • the CMS record shows $155,366 in federal fines (most recent 2026-01-06)
  • its payroll-based staffing score sits well above its independent inspection score

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

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

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

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1309 Savannah Ln · (800) 323-2510 · Call to confirm hours
Pharmacy
145 S Eastwood Dr · (815) 206-0716 · Call to confirm hours
Grocery
1013 N Seminary Ave · (815) 338-2929 · Call to confirm hours
Park
2105 Paulsen Rd · (815) 338-6223 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 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 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased9.5%13.4%15.4%better
Long-stay residents who lose too much weight7.8%6.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.5%0.9%0.9%better
Long-stay residents with a urinary tract infection3.5%1.5%2.0%worse
Long-stay residents with depressive symptoms5.3%54.2%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.4%3.1%3.3%better
Long-stay residents whose ability to walk worsened15.4%14.3%16.1%typical
Long-stay residents on antianxiety or hypnotic medication17.8%18.3%18.9%typical
Long-stay residents given the seasonal flu vaccine85.9%91.8%95.3%typical
Long-stay residents with pressure ulcers4.1%4.8%4.7%better
Long-stay residents with worsening bladder/bowel control17.0%20.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table18.9%21.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.4%2.2%1.4%better
Short-stay residents given the seasonal flu vaccine66.4%63.1%79.4%worse
Short-stay residents rehospitalized after admission23.8%26.1%22.6%typical
Short-stay residents with an outpatient ER visit10.7%13.9%12.0%better
Long-stay hospitalizations per 1,000 resident days2.562.021.67worse
Long-stay outpatient ER visits per 1,000 resident days1.302.221.80better

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.

63.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 238 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

63.8%U.S. median 51.5%
Got home and stayed home
12.0%U.S. median 10.7%
Went back to hospital
36.5%U.S. median 56.6%
Met the expected recovery
0.20U.S. median 0.31
Therapy hours / resident / day
0.10hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 36.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 126 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 0.20 therapist hours per resident per day in 2026Q1 — more than 23% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 24% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF63.8%CMS range 57.9–69.351.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.0%CMS range 9.2–15.710.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge36.5%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge27.8%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge49.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot 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 discharge96.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.0%CMS range 4.1–9.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.921.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

1.27
RN hours/ resident / day
0.55
LPN hours/ resident / day
2.89
Aide hours/ resident / day
4.71
Total nurse hours/ resident / day
1.16
RN hoursweekends
33.9%
Total nursing turnover
16.7%
RN turnover

How full it usually is: this home is certified for 128 beds and averages 98.8 residents a day — about 77% occupied, or roughly 29 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 4.71 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.27 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.89 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.20 hrs/resident/day on weekends vs 4.91 on weekdays — 15% thinner on weekends. RN hours go from 1.32 to 1.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 34% is below 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

8
deficiencies at the latest standard inspection (2026-03-04)
14
at the previous standard inspection (2024-03-20)

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.

ABCDEFGHIJKL

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

30 citations, most serious first. The 12 most serious are shown; the remaining 18 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2024-03-20 · 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 ensure residents were served food at a safe temperature. This failure resulted in R273 spilling hot soup and receiving full thickness burns on his right forearm and abdomen. The facility failed to safely transfer residents with a mechanical lift. The facility failed to ensure medications were stored in a safe manner away from a cognitively impaired resident. The facility also failed to ensure residents at risk for choking were supervised during meal times and provided thickened liquids as prescribed. This applies to 6 of 18 residents (R17, R9, R51, R52, R53 & R273) reviewed for safety and supervision in the sample of 18. The failure to ensure safe food temperatures resulting in R273 sustaining a burn due to hot foods resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 6/5/23 when the facility failed to ensure residents were served soup at a safe temperature to prevent burns. V1 Administrator was notified of the Immediate…

    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 before2026-01-06 · 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

    Based on observation, interview, and record review the facility failed to ensure fall precautions were updated and in place for residents at risk for falls for 2 of 3 residents (R1, R3) in the sample of 3. This failure resulted in R1 falling and sustaining a head injury.The findings include:The facility's Incident Report dated 1/1/26 shows At approximately 6:49 AM, R1 was screaming for help from her bed and bed alarms were sounding. The Certified Nursing Assistant (CNA) (V5) acknowledged her and the resident states she needed to go to the bathroom. Resident was assisted to the bathroom with her walker and placed on the toilet. R1's call light was turned on and CNA returned to assist resident off the toilet around 7:00 AM. V5 entered bathroom and witnessed R1 lying on the bathroom floor.V5's Resident Incident/Accident Report Employee Statement dated 1/1/26 shows At Around 6:44 AM, I came in to help R1 because she was screaming for help, but she was in bed and then stated she needed to use the bathroom, so I helped her with the walker, put her in there in the toilet. Came back around…

    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 · Ecited before2026-03-04 · tag F0805 — failed to prepare food in a form residents can eat — pattern
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    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 soft and bite sized foods were cut to 1/2 (inch) x (by) 1/2 x 1/2 sizes before plating and serving. This applies to 4 of 4 residents (R36, R64, R105, and R97). The findings include: Facility provided diet order list dated 3/2/26, shows R36 has a diet order of easy to chew with bite sized meats. R105, R64, and R97 have a diet order of soft and bite sized with ground meats. R124 has a diet order of soft and bite sized. 1. On 3/2/26 at 11:24 AM, V14 (Cook) started setting up the second floor kitchenette for service. This included a pan of coined glazed carrots and a pan of a full pot roast, not yet sliced. V14 removed the tin foil covering the pot roast and took a knife to cut the pot roast into approximately one inch sections across the short side of the pot roast, making large slices of pot roast. During service, at 11:54 AM, V14 was seen removing a portion of the large slice, turned it on its face, then diced it into large cubes. At 12:00 PM, V14 placed coined carrots on plates with diced pot roast and…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-04 · tag F0638 — isolated
    Assure that each resident’s assessment is updated at least once every 3 months.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review the facility failed to perform MDS-Minimum Data Set assessments every 3 months (92 days) for 3 of 7 residents (R26, R31, R61) reviewed for MDS assessments in the sample of 24.The findings include:On 03/03/2026 R26's MDS assessment has not been performed for 133 days. The MDS started 01/12/2026 shows, in process. R26's last completed MDS assessment was dated 10/20/2025.On 03/03/2026 R31's MDS assessment has not been performed for 126 days. The MDS started 01/26/2026 shows, in process. R31's last completed MDS assessment was dated 10/31/2025.On 03/03/2026 R61's MDS assessment has not been performed for 126 days. The MDS started 01/20/2026 shows, in progress. R61's last completed MDS assessment was dated 10/27/2025.On 03/03/2026 at 12:03 PM, V18 (MDS Coordinator) said, all disciplines must complete the resident assessment before it can be submitted. The MDS assessments should have been completed and submitted sooner. On 03/04/2026 V1 (Administrator) did not provide an MDS policy.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-04 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to accurately reflect R3 and R29's status in the MDS-Minimum Data Set for 2 of 7 residents reviewed for accurate MDS in the sample of 24. The findings include:1.R3's Medical Record-Census on [DATE] shows, R3 expired on [DATE].On [DATE] R3's Medical Record did not have a discharge Minimum Data Set (MDS) assessment. The MDS dated [DATE] shows, Admission. On [DATE] at 12:03 PM, V18 (MDS Coordinator) said, (R3) passed away in 12/2025. I missed updating (R3's) MDS.2. R29's Medical Record-Census on [DATE] shows, R29 was discharged [DATE].On [DATE] R29's Medical Record did not have a discharge MDS. The current MDS dated [DATE] shows, In Process.On [DATE] at 12:03 PM, V18 (MDS Coordinator) said, (R29) was discharged [DATE] and that (R29) passed away in the hospital. The MDS nurse for (R29) has resident care duties and fills in when the residents need help. (R29's) MDS needs to be finished.On [DATE] V1 (Administrator) did not provide an MDS policy.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-04 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to ensure a resident who is dependent on staff received assistance with incontinence care. This applies to 1 of 24 residents (R2) reviewed for activities of daily living in the sample of 24. The findings include: On 03/02/2026 at 10:29 AM, R2 was in his room lying in bed, a strong foul odor was present. He said he had an accident. V11 and V12 (Certified Nursing Assistants) removed R2's incontinence brief. R2's incontinence brief was heavily soiled with large amounts of stool from his backside to his lower back. R2's stool soiled through his pants and incontinence pad. V12 asked V11, did the pants have stool on there too? V11 said yes, his pants were soiled with stool. On 03/02/2026 at 10:40 AM, R2 said he was last changed before breakfast and waited a long time for staff assistance.On 3/02/2026 at 12:02 PM, V7 (Licensed Practical Nurse-LPN) said R2 is alert and oriented, he is totally dependent on staff for cares including incontinence care. Staff should check and change him every two hours. R2's current care plan…

    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 before2026-03-04 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an ordered treatment was in place for one of 24 residents (R42) reviewed for Quality of Care in the sample of 24.The findings include:R42's Face Sheet shows she was admitted to the facility on [DATE], with diagnoses including dementia, chronic diastolic congestive heart failure, atrial fibrillation, hypertension, osteoarthritis, muscle weakness, and localized edema.R42's Orders show an order for Treatment: [NAME] Hose/Tubi Grips special instructions: apply to bilateral (both) lower extremities for edema in the early morning and off at bedtime twice a day. This order started November 20, 2025.On March 2, 2026, at 10:27 AM, V19 (Certified Nursing Assistant-CNA) brought R42 to the bathroom. There were two pairs of tubi grips hanging up on the wall bars that were clean. R42 did not have on ted hose/tubi grips to her lower extremities, nor did the CNA offer to put them on R42. R42's bilateral lower legs were dry and discolored. There…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-04 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to apply an ordered medicated patch. This applies to 1 of 4 residents (R2) reviewed for medication administration in the sample of 24. The findings include: On 03/02/26 at 10:29 AM, V11 and V12 (Certified Nursing Assistants) provided incontinence care to R2. R2 was heavily soiled with stool from his backside to his lower back. V11 said, He's going to need a new patch. R2's patch was soiled with stool. V11 removed the soiled patch and notified V6 (Registered Nurse- RN). On 03/02/26 at 10:55 AM, V6 (RN) entered R2's room. V6 said the lidocaine patch was placed this morning and removed at night. V6 said I can't put another one on. The patch is on for 12 hours and he's (R2) had it on for 5 hours. V6 said, We are normally not supposed to put on another patch if it comes off. On 03/02/26 at 2:00 PM, R2 was in his room lying in bed. He said V6 has not put the patch back on. On 03/04/26 at 10:03 AM, V5 (RN) said if a resident's medicated patch is removed before the scheduled duration she would call the physician for…

    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 · D2026-03-04 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure 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

    Based on interview and record review, the facility failed to ensure the medication regime review was addressed by the physician. This applies to 1 of 5 residents (R2) reviewed for medication review in the sample of 24. The findings include: R2's Pharmacist's Recommendation to Prescriber report dated 2/6/26 shows, (R2) has been ordered the psychotropic medication Escitalopram 20 mg (milligrams) daily. May we attempt a trial dose reduction to Escitalopram 15 mg (milligrams). The prescriber's response and signature are left blank. On 3/4/26 at 11:41 AM, V2 (Director of Nursing) said, The medication reviews are reviewed monthly in our behavior committee. The facility recently switched providers for psych (psychiatric) services and they did not address the medication reviews from last month. R2's Physician Order Sheets dated March 2026 shows orders for Escitalopram 20 mg daily for anxiety. The facility's Psychotropic Medication Reduction Program Policy reviewed 2022 states, The resident's medication regime will be managed and monitored to promote or maintain the resident's highest…

    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 · D2026-03-04 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    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 the served portions of pureed pot roast, pureed pork stir fry, pureed carrots, and pureed soup were served at the appropriate serving size. This applies to 2 of 2 residents (R60, R78) reviewed for pureed foods in the sample of 24. The findings include: Facility provided diet order list dated 3/2/26, shows R60 and R78 receive pureed foods for meals and reside on the second floor. On 3/2/26 at 11:24 AM, V14 (Cook) began preparing for lunch service in the second floor kitchenette by placing the food service pans into and on top of the steam table. V14 finished preparing by placing a green handle scoop into the puree [NAME] pot roast, puree pork stir fry with vegetables, puree glazed carrots, and the puree cream of mushroom soup. V14 said the green handle scoops provide approximately 3 ounces. Menu spreadsheet for the 3/2/26 lunch meal shows the serving sizes should have been as follows: 4 ounces for the [NAME] pot roast, 1 cup (8…

    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 · Dcited before2024-09-16 · 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

    Based on interview and record review the facility failed to immediately verify a resident (R1) had not eloped from the facility after an exit door alarm sounded. The facility alos failed to supervise a resident (R1) in a manner to prevent that resident from eloping from the facility. These failures apply to 1 of 3 residents (R1) reviewed for safety/supervision in the sample of 3. The findings include: R1's progress notes dated 9/8/24 showed R1 was found outside of the facility around 1:30 AM. The notes showed R1 was last seen in bed by staff at 12:45 AM. The notes showed, At 1:12 AM, a (first-floor) door alarm was going off for the northwest courtyard door. Checked the door, no one seen outside, but is was dark. At 1:15 AM, resident not found in bed or bathroom . Search for resident commenced. Resident was seen though window . outside (of facility) by northwest courtyard . The notes showed staff immediately brought R1 back into the building. R1 appeared confused. R1 sustained no injuries or falls during the elopement. R1 was placed on every 15 minutes checks by staff, a wanderguard…

    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 · D2024-04-08 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to resolve a grievance/concern verbalized by a resident's POA (power of attorney) for 1 of 3 residents (R1) reviewed for grievances in the sample of 3. The findings include: R1's care plan dated 3/12/24 showed R1 was cognitively impaired due to her diagnosis of dementia. The care plan showed R1 was at risk for falls due to her impaired cognition, impulsivity, weakness and poor safety awareness. A progress note for R1, dated 12/4/23, showed, POA must be notified at time of event of any change in condition or any care item added to the care plan. R1's fall incident report dated 3/23/24 showed R1 sustained an unwitnessed fall in the bathroom. R1 received no injuries from the fall. The report showed V10 (R1's POA) was not notified of R1's fall until 4/2/24. On 4/8/24 at 11:33 AM, V10 (R1's POA) stated, My concerns with a lack of communication from the facility have been going on for months. I have had multiple conversations and sent emails back and forth with (V1 Administrator) about the lack of communication from the facility. We…

    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
Show the remaining 18 citations
  • Potential for harm · E2024-03-20 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to ensure opened, multi-dose vials of medication, including inhalers and gels, were labeled with expiration dates. The facility failed to discard an expired medication. These failures apply to 5 of 5 residents (R23, R12, R41, R19, R31) reviewed for medication storage in the sample of 18. The findings include: 1. R23's March 2024 Prescription Order form showed R23 was prescribed an Albuterol Sulfate inhaler, 90 mcg (micrograms), inhale 2 puffs, twice a day. On 3/18/24 at 9:36 AM, a second floor medication cart was reviewed with V11 Licensed Practical Nurse (LPN). One opened, undated, albuterol inhaler, prescribed to R23, was found in the top drawer of the cart. V11 LPN stated, She (R23) gets that (inhaler) twice a day. It should be dated when opened so we know when it expires. I think inhalers are good for 90 days when opened. 2. R12's prescription order dated 10/26/21 showed R12 was prescribed Latanoprost 0.005% eye drops, one drop to each eye, once a day for her glaucoma. The order showed a bottle of the eye…

    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 · E2024-03-20 · tag F0887 — pattern
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    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 screen for and offer the COVID-19 immunization to residents for 4 of 5 residents (R64, R38, R59, R65) reviewed for the COVID-19 immunization in the sample of 18. The findings include: 1. R64's Resident Face Sheet showed R64 was admitted to the facility on [DATE]. R64's Preventative Health Record form printed 3/19/24 showed no documentation of R64 receiving any doses of the COVID-19 vaccination. R64's admission records and progress notes dated 10/30/24-3/18/24 showed no documentation R64 was ever screened for or offered the COVID-19 vaccine while in the facility. A progress note for R64, dated 3/19/24 at 11:12 AM, showed, Left message for POA (power of attorney) regarding consent for COVID vaccine, awaiting return call. 2. R38's Resident Face Sheet showed R38 was admitted to the facility on [DATE]. R38's Preventative Health Record form printed 3/18/24 showed R38 last received a dose of the COVID-19 vaccination on 12/16/21. R38's admission records 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-20 · 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 observation, interview, and record review, the facility failed to ensure a non-pressure sacral wound was treated, as ordered, for 1 of 5 residents (R370) reviewed for non-pressure wounds in the sample of 18. The findings include: On 3/18/24 at 9:36 AM, R370 said she has a wound to her bottom and staff have been applying cream to the area. On 3/18/24 at 9:38 AM, V24, Certified Nursing Assistant (CNA), took R370 to the bathroom. R370 had no dressing to her sacrum. On 3/18/24 at 9:49 AM, V6, Wound Care Nurse, said she saw documentation in the wound book showing R370 has an open area to her bottom, but R370 is not seeing the wound doctor at this time. R370 was back in her bed and said her bottom hurts. R370 had an open wound to her sacrum. V6 cleaned the wound with normal saline, measured the wound, then applied barrier cream. On 3/20/24 at 10:18 AM, V6 said R370's sacral wound is not a pressure ulcer, but she will have the wound care doctor see it this upcoming Monday. R370's Physician Order Report for the dates 2/18/24 through 3/18/24 shows a treatment order was placed on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-20 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to ensure a catheter drainage bag was maintained below the level of the bladder for 1 of 1 residents (R49) reviewed for catheters in the sample of 18. The findings include: On 3/18/24 at 1:54 PM, V23 and V24, CNAs (certified nursing assistants) were using a mechanical lift to transfer R49 from his wheelchair to his bed. V23 and V24 hung R49's catheter bag on the sling strap above R49 as they raised R49 with the lift. Once R49 was lying in bed, V23 told V24 to set R49's catheter drainage bag on his bed where it remained as they provided a bed bath. On 3/19/24 at 1:25 PM, V25, CNA, said the catheter drainage bag should be positioned lower than the bladder so urine does not go back up in the bladder. If urine backflows back into the bladder, the resident could get a urinary infection, chronic kidney disease, and neuromuscular bladder dysfunction. R49's Face Sheet printed 3/20/24 shows his diagnoses include, but are not limited to, quadriplegia, diabetes mellitus type 2, chronic kidney disease, and neuromuscular…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-20 · 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 staff failed to ensure a resident took all medications during medication administration. This applies to 1 of 3 (R48) reviewed for medication administration in the sample of 18. The findings include: 1. On 3/19/2024 at 8:29AM, V16 License Practical Nurse (LPN) prepared the medications for R48's medication administration. V16 placed the pills into a medication cup and dissolved the Miralax into a cup of water. V16 went to administer the medications to R48 at 8:40AM. V16 watched the resident take her pills and left the cup of water with MiraLAX on the resident's breakfast table in the dining room. R48 did not drink the MiraLAX and water. V16 was observed talking to other residents on the opposite side of the dining room from R48 while the MiraLAX was still sitting next to R48. At 8:51AM the MiraLAX in water was [NAME] sitting on the table next to R48, untouched by the resident. On 3/19/2024 at 8:51AM, Surveyor asked V16 about the MiraLAX sitting 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-20 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review the facility failed to ensure PRN (as needed) anti-anxiety (psychotropic) medications had a duration/end date. This applies to 2 of 5 (R53, R63) reviewed for unnecessary medications in the sample of 18. The findings include: On 3/19/2024, R53's Orders show resident has an active order since 7/18/2023 for lorazepam give 0.5mg/0.25mL PO (by mouth) Q (every) 2 hours PRN (as needed) for anxiety, agitation, or restlessness, with no stop date. On 3/19/2024, R63's Orders show resident has an active order since 2/27/2024 for lorazepam give 0.5mg tab PO Q 4 hours PRN for anxiety, with no stop date. On 3/20/2024 at 9:58AM, V2 Director of Nursing (DON) said PRN psychotropic and antipsychotic medications should have a 14 day stop date. The facility's Procedure for Psychotropic Medication Evaluation policy reviewed 3/2022 states . PRN medications psychotropic medications . will be limited to 14 days.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-20 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    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 serve pureed barbecue beef brisket at safe temperatures. This applies to 3 of 3 residents (R46, R28, R10) reviewed for pureed diets in the sample of 18. The findings include: R46's lunch meal ticket for 3/18/24 shows that R46 received pureed barbecue beef brisket. R28's lunch meal ticket for 3/18/24 shows that R28 received pureed barbecue beef brisket. R10's lunch meal ticket for 3/18/24 shows that R10 received pureed barbecue beef brisket. On 3/18/24 at 11:59 AM, V20 (Cook) took food temperatures before plating lunch. The pureed barbecue beef brisket was at 130°F. This surveyor repeated the temperature to V20 and V20 confirmed the pureed barbecue beef brisket was at 130°F. V20 did not bring the pureed barbecue beef brisket back to the kitchen to be reheated prior to service. Facility provided temp log for the second floor kitchenette dated 3/17/24 shows the pureed entree was at 157°F; a different temperature than what was confirmed during service by V20. On 3/19/24 at 11:44 AM, V4 (Dietary Manager) said 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-20 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    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 pureed barbecue beef brisket in a smooth, pudding-like consistency for residents requiring a pureed diet. This applies to 3 of 3 residents (R46, R28, R10) reviewed for pureed diets in the sample of 18. The findings include: R46's lunch meal ticket for 3/18/24 shows that R46 received pureed barbecue beef brisket. R28's lunch meal ticket for 3/18/24 shows that R28 received pureed barbecue beef brisket. R10's lunch meal ticket for 3/18/24 shows that R10 received pureed barbecue beef brisket. On 3/18/24 at 12:58 PM, facility provided test tray of pureed barbecue beef brisket, pureed squash, and pureed chicken noodle soup was evaluated. The pureed barbecue beef brisket was not smooth and required chewing. On 3/18/24 at 1:10 PM, V4 (Dietary Manager) said before testing the pureed barbecue beef brisket that he could already tell it was not a proper consistency. V4 said that it was stringy and not the proper consistency. The proper consistency for pureed food items is completely smooth, no chunks, and similar…

    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 · D2024-03-20 · tag F0825 — isolated
    Provide or get specialized rehabilitative services as required for a 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 evaluate a resident for Physical Therapy (PT) after receiving an order to start PT for 1 of 5 residents (R17) reviewed for rehab/therapy in the sample of 18. The findings include: On 03/19/24 at 09:24 AM V27, R17's daughter, said the facility did not start therapy when the neurologist ordered it in October of 2023; they never started it until December 2023. On 3/19/24 at 11:33 AM, V7, Rehab Coordinator, said the physician can order therapy for a resident if they see a decline or would like an evaluation. V7 said when a resident comes back from their doctor's appointment, they send a packet with the resident and the nurse enters the orders and a copy of the order is given to her. V7 said all therapy will begin with an evaluation and therapy should start the evaluation within a week of it being ordered. V7 said delaying a therapy evaluation/treatment by two months could potentially contribute to a decline in the resident's function. R17's Neurologist's Progress Notes dated 10/4/23 shows he recommends dedicated physical…

    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 · D2024-03-20 · tag F0847 — isolated
    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to ensure the facility's binding arbitration agreement was explained to a resident in a form and manner that the resident could understand for 2 of 3 residents (R274, R59) reviewed for binding arbitration agreements in the sample of 18. The findings include: 1. R274's binding arbitration agreement dated 3/6/24 showed the agreement was signed by R274. On 3/19/24 at 12:26 PM, R274's binding arbitration agreement, dated 3/6/24, was reviewed by R274 and this surveyor. The agreement showed R274 initialed and/or signed each area of the binding arbitration agreement. When this surveyor handed the agreement to R274 for her to review, R274 stated, You will have to read this to me. I am legally blind. I can't read it. When this surveyor started to read the agreement to R274, R274 stated, No one read this part to me before! (V8 Concierge) just told me to sign it. If someone had read that to me, I would have never signed that. I thought I was signing my admission stuff. On 3/19/24 at 12:30 PM V8 Concierge stated she reviews the binding…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-20 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to screen for and administer influenza (flu) and pneumococcal immunizations to residents for 2 of 5 residents (R64, R19) reviewed for influenza and pneumococcal immunizations in the sample of 18. The findings include: 1. R64's Resident Face Sheet showed R64 was admitted to the facility on [DATE]. Influenza and Pneumococcal Vaccine Consent forms dated 11/6/23 for R64 showed R64's POA (power of attorney) gave consent for R64 to receive both vaccinations. R64's Preventative Health Care Record Form printed 3/19/24 showed R64 did not receive the influenza vaccination until 3/19/24. The form also showed R64 last received a pneumococcal vaccine (PPSV23) on 1/10/13 which showed R64 was eligible to receive an additional pneumococcal vaccine (PCV 20). R64's medication administration records dated 10/30/23-3/19/24 were reviewed and showed R64 had yet to receive a pneumococcal vaccination in the facility. 2. R19's Resident Face Sheet showed R19 was admitted to the…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-20 · tag F0908 — failed to keep essential equipment working — isolated
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure resident care equipment was in safe working order. This applies to 2 of 18 residents (R24 & R37) reviewed for safe operating equipment in the sample of 18. The findings include: 1. R37's facility event report dated January 11, 2024 shows, mechanical lift failure R37 already lying on bed. Evaluation Notes: On 1/11/24 an incident involving the mechanical lift occurred. After completion of a [mechanical lift] to bed was complete, the lift began to self lower on top of resident's right shoulder . [mechanical lift] was taken out of service for maintenance. R37's progress notes dated January 11, 2024 shows, At 8:30 p.m. while CNAs were transferring her (R37) into bed with easy lift, they had completed transfer, R37 was lying on bed the aides were unhooking sling from bars of lift there was a loud bang sound and lift lowered onto R37 with bar of lift pressing into her right shoulder . On March 19, 2024 at 9:32 AM, R37 stated, something was wrong with…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-20 · tag F0940 — failed to train staff — isolated
    Develop, implement, and/or maintain an effective training program for all new and existing staff members.
    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 mechanical lift training to facility staff using lifts for resident's requiring mechanical lifts for transfers. This applies to 1 of 1 (R48) reviewed for training requirements. On 3/19/2024 at 11:45AM, V17 Home Health Aide said she had not received any training on the Hoyer lifts from the facility. V17 said she was transferring [R48] with the assistance of V14 - Certified Nursing Assistant. V17 said the Hoyer lift started to tip and [R48] bumped her head on the lift, no bleeding or bruising noted. On 3/19/2024 at 12:27PM, V7 Licensed Practical Nurse (LPN)/ Rehab Coordinator said she does not believe [V17] received Hoyer lift training. V7 said training is offered and those people working that day receive training. V7 said the facility is responsible for Hoyer lift training. On 3/19/2024 at 1:27PM, V2 Director of Nursing (DON) said staff using a Hoyer lift should be trained on the lift. R48's Care Plan, revised on 1/23/2024 states . At this time [R48] needs max asst with adl's. Transfers with total mechanical, w/c…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-02-09 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — 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 catheter drainage bags and tubing were not laying on the floor or bed. The facility failed to ensure expired catheter supplies were removed from use for 4 of 4 residents ( R19, R65, R69 & R141) reviewed for catheters in the sample of 20. The findings include: 1. On [DATE] at 10:15 AM, V5 CNA (Certified Nursing Assistant) had R141 on the toilet in the bathroom to have a bowel movement. V5 washed, rinsed and dried R141's anal area and buttocks when R141 was done using the bathroom. V5 pulled up R141's incontinence brief and pants. V5 transferred R141 to her wheelchair. R141's indwelling urinary catheter bag was under her wheelchair without a cover in place. V5 wheeled R141 into her bedroom and placed a tray table in front of her. R141's catheter bag was folded over under her wheelchair and partially laying on the floor. R141 had catheter tubing laying on the floor. V5 stated the only catheter care she provides is emptying of the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-09 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    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 prevent the theft of $40 from a resident's wallet. This applies to 1 of 3 residents (R54) reviewed for abuse in the sample of 20. The findings include: R54's Face Sheet showed she was admitted to the facility on [DATE] with diagnoses to include: reduced mobility, artificial hips, and a traumatic fracture. (No dementia or psychiatric diagnoses listed.) R54's 1/3/23 Minimum Data Set (MDS) showed she was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. On 2/09/23 at 9:30 AM, V14 Certified Nursing Assistant said, I heard through the grape vine that she (R54) had money go missing. She is alert, oriented, and reliable. On 2/7/23 at 11:28 AM, R54 was in her room and she was using a wheelchair to self-propel herself about her room. R54's room was clutter free and well decorated. R54, as well as all residents of the second floor, had her own free-standing closet with drawers. R54's free-standing closet was…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-09 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to report to the local health department and local law enforcement the reasonable suspicion of resident theft. This applies to 3 of 3 residents (R54, R64, & R283) reviewed for abuse in the sample of 20. The finding include: 1. R54's Face Sheet showed she was admitted to the facility on [DATE] with diagnoses to include: reduced mobility, artificial hips, and a traumatic fracture. (No dementia or psychiatric diagnoses listed.) R54's 1/3/23 Minimum Data Set (MDS) showed she was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. On 2/7/23 at 11:28 AM, R54 was in her room and she was using a wheelchair to self-propel herself about her room. R54's room was clutter free and well decorated. R54, as well as all residents of the second floor, had her own free-standing closet with drawers. R54's free-standing closet was next to her bed and could not be mistaken for her roommate's closet. R54's roommate, (R64) was 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-09 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to identify allegations of theft as being allegations of abuse and then failed to conduct a complete investigation of abuse. This applies to 3 of 3 residents (R54, R64, & R283) reviewed for abuse in the sample of 20. The finding include: 1. R54's Face Sheet showed she was admitted to the facility on [DATE] with diagnoses to include: reduced mobility, artificial hips, and a traumatic fracture. (No dementia or psychiatric diagnoses listed.) R54's 1/3/23 Minimum Data Set (MDS) showed she was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. On 2/7/23 at 11:28 AM, R54 was in her room and she was using a wheelchair to self-propel herself about her room. R54's room was clutter free and well decorated. R54, as well as all residents of the second floor, had her own free-standing closet with drawers. R54's free-standing closet was next to her bed and could not be mistaken for her roommate's closet. R54's…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-09 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 follow physician orders by administering insulin to a resident experiencing a low blood sugar level and failed to follow facility standing orders for treating low blood sugars for 1 of 1 resident (R35) reviewed for medications. The findings include: R35's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include palliative care, acute respiratory disease, Type 2 diabetes mellitus with ketoacidosis without coma, anxiety disorder, atrial fibrillation, and history of malignant neoplasm of bronchus and lung. R35's facility assessment dated [DATE] showed he has severe cognitive impairment and requires extensive assist for most cares. R35's December 2022 eMAR (electronic Medication Administration Record) showed glucose levels as follows: 12/9/22 at 7:30 AM, 46 mg/dl; 12/9/22 at 4:30 PM, 50 mg/dl; 12/10/22 at 7:30 AM, 39 mg/dl; 11:30 AM, 61 mg/dl; 4:30 PM, 51 mg/dl; 9:00 PM, 49 mg/dl; 12/12/22 at 7:30 AM, 61 mg/dl;…

    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

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

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$155,366 in federal fines across 3 penalties. 2 Medicare payment denials on record.

  • $16,660 — penalty dated 2026-01-06
  • $73,150 — penalty dated 2025-04-23
  • $65,556 — penalty dated 2024-03-20
  • Medicare payment denial — starting 2025-05-16 for 31 days
  • Medicare payment denial — starting 2024-04-16 for 34 days

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

Who owns this facility

Owner / managerTypeRoleSince
ANNARELLA, THOMASIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2014
EGEKEZE, GILBERTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/05/2024
PARTRIDGE, NICKIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/24/2025
POLTE, TARAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/17/2015
TOLLBERG, BRITTANYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/30/2023

CMS files one row per role, so the 10 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

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

$12.6M
Net patient revenuemost recent cost report
-16.2%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 48%Medicare 20%Other / private 32%

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

$528per resident / day
operating cost
$16,059per month
≈ monthly operating cost
$455per day
avg. revenue, all payers

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

What families pay in IL

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.

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

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145652. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-04, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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