Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 46 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
5G
0H
0I
Potential for more than minimal harm
33D
7E
1F
Potential for minimal harm
0A
0B
0C
July 7, 2026Complaint inspection · 1 citation
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident meals were provided on time for 10 of 10 residents (R1-R7 and R10-R12) reviewed for resident rights in the sample of 12.
June 30, 2026Complaint inspection · 1 citation
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation, interview and record review the facility failed to maintain a clean environment for seven residents. This applies to seven of ten residents (R1-R7) reviewed for environment in the sample of ten.
April 1, 2026Complaint inspection · 2 citations
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, interview, and record review the facility failed to maintain the south shower room in a safe, sanitary, functional and comfortable condition for residents. This applies to 51 residents residing on the south wing.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review the facility failed to provide adequate supervision to a resident with a history of falling for 1 of 3 residents (R1) reviewed for falls in the sample of 6.
December 24, 2025Complaint inspection · 2 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review the facility failed to provide ordered wound care for 2 of 3 residents (R2 and R3) reviewed for nursing care/wound care in the sample of 13.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide ordered medications and failed to administer the correct medication. This applies to 2 of 5 (R5 & R1) reviewed for medications in the sample of 13.
December 6, 2025Complaint inspection · 1 citation
- F
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that dietary support staff completed a food handler's training course within thirty days of hire and failed to have a policy in place to ensure dietary staff complete this required training for safe food handling per Illinois Department of Public Health (IDPH) regulations. This failure affects all 80 residents who currently reside at the facility.
June 23, 2025Complaint inspection · 1 citation
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review the facility failed to follow wound treatment orders for 1 of 3 residents (R1) reviewed for wounds in the sample of 3. This failure resulted in R1's wound deteriorating and requiring R1 to be hospitalized and recieve a surgical intervention.
May 12, 2025Complaint inspection · 1 citation
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review the facility failed to ensure a resident was not verbally abused by staff. This applies to 1 of 4 (R1) reviewed for abuse in the sample of 4.
March 19, 2025Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review the facility failed to safely reposition a resident in bed for one of three residents (R1) reviewed for safety/supervision in the sample of three. This failure resulted in R1 rolling out of bed onto the floor and experiencing increased pain and a humeral fracture. This past noncompliance occurred from March 11, 2025- March 17, 2025.
March 7, 2025Complaint inspection · 2 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review the facility failed to identify a wound prior to becoming an unstageable wound, failed to have pressure ulcer interventions in place, and failed to ensure wound treatment orders were in place for 2 of 3 residents (R1, R2) reviewed for pressure ulcers in the sample of 3. These failures resulted in R1 being at an increased risk of infection and delayed wound healing.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview, and record review the facility failed to notify a resident representative of an advanced stage wound for 1 of 3 residents (R1) reviewed for notification of changes in the sample of 3.
February 21, 2025Complaint inspection · 1 citation
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review, the facility failed to identify that a resident who is at risk for developing pressure injuries and who had a pressure injury would be at a higher risk for developing a second pressure injury; and failed to implement preventative measures and adequate skin assessments for 1 of 4 residents (R1) reviewed for wounds in a sample size of 7. This failure resulted in R1 developing two pressure injuries to the back of his ears that were both identified at a stage 3 when found.
January 8, 2025Complaint inspection · 2 citations
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview and record review the facility failed to notify the physician of an ongoing change in condition in a timely manner. This applies to 1 of 3 residents (R1) reviewed for notification of changes in the sample of 5.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review the facility failed to identify and assess a resident for an ongoing change in condition. This applies to 1 of 3 residents (R1) reviewed for quality of care in the sample of 5.
October 15, 2024Complaint inspection · 1 citation
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review the facility failed to ensure medication orders were verified prior to administering medications for 1 of 4 residents (R1) reviewed for pharmacy services in the sample of 8.
September 17, 2024Complaint inspection · 1 citation
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview and record review, the facility failed to implement their abuse policy by not removing staff from resident care during an abuse investigation for 1 of 3 residents (R1) reviewed for abuse in the sample of 6.
July 17, 2024Standard inspection, Complaint inspection · 9 citations
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wrote4. On 7/15/24 at 9:58 AM, R61's bed (hospital bed that raised up and down) and air mattress pump were plugged into a power strip. 5. On 7/15/24 at 10:17 AM, R11 had an air mattress pump hanging on the headboard of the bed. The air mattress pump was plugged into a power strip. 6. On 7/15/24 at 10:03 AM, R53 had an air mattress pump hanging on the headboard of the bed. The air mattress pump was plugged into a power strip. On 7/15/24 at 12:40 PM, V12 (Maintenance Director) said medical equipment should be plugged into wall outlets and not power strips. V12 added power strips are not used because they can be turned off or easily lose power. V12 said medical equipment should be plugged into a wall outlet because a wall outlet provided a more reliable source of electricity. [...]
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview and record review the facility failed to prepare and distribute food in accordance with professional standards for food service safety. This applies to 5 of 5 (R3, R26, R14, R36, R23) residents reviewed for pureed diets in the sample of 74.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure incontinence care was provided for a resident dependent on staff for cares. This applies to 1 one 18 residents (R18) reviewed for Activities of Daily Living (ADL's) in the sample of 18.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review the facility failed to provide the necessary treatment for a resident's fractured arm. The facility failed to obtain daily weights for a resident with a diagnosis of congestive heart failure. These failures apply to 2 of 18 residents (R34, R18) reviewed for quality of care in the sample of 18.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview and record review the facility failed to obtain physician prescribed medication and failed to follow physician orders for eye drops for 2 of 18 residents (R2, R32) reviewed for physician services in the sample of 18.
- D
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.
Inspectors wroteBased on interview and record review the facility failed to ensure a resident on a PRN (as needed) antipsychotic medication was evaluated by a physician after 14 days and failed to monitor a resident for antipsychotic side effects by not doing an AIMS (Abnormal Involuntary Movement Scale) test every 6 months for 2 of 5 residents (R32, R11) reviewed for psychotropic medications in the sample of 18.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review the facility failed to administer physician prescribed medications as ordered. There were 29 opportunities with 3 errors resulting in a 10.34% error rate. This applies to 2 of 4 residents (R2, R12) observed during medication pass.
- D
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Inspectors wroteBased on interview and record review the facility failed to explain binding arbitration in a manner the resident understood. This applies 1 of 3 (R68) in the sample of 18 reviewed for arbitration.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff wore Personal Protective Equipment (PPE) for a resident on Contact Isolation and a resident on Enhanced Barrier Precautions for 2 of 18 residents (R6, R16) reviewed for infection control in the sample of 18.
November 17, 2023Complaint inspection · 1 citation
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a safe transfer for 1 of 3 residents (R1) reviewed for safety in the sample of 3.
October 11, 2023Complaint inspection · 1 citation
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fall interventions were in place for 1 of 3 residents (R2) reviewed for falls in the sample of 8.
September 27, 2023Complaint inspection · 1 citation
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) assistance for residents' requiring extensive assistance with ADLs for two of three residents (R2, R3) reviewed for ADL assistance in the sample of three.
August 16, 2023Standard inspection · 9 citations
- E
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.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure multidose insulin pens were labeled with an open date for 4 of 4 (R59, R8, R33, R37) residents reviewed for medication storage in the sample of 18.
- E
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.
Inspectors wroteBased on observation, interview, and record review the facility failed to follow their lunch menu by not serving the pureed bread option for four of four residents (R45, R60, R19, R36) reviewed for food menus in the sample of 18.
- D
Plan the resident's discharge to meet the resident's goals and needs.
Inspectors wroteBased on observation, interview and record review the facility failed to assist a resident with discharge planning. This applies to 1 of 18 residents (R35) reviewed for discharge planning in the sample of 18.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and record review the facility failed to provide ADL (activities of daily living) assistance for residents' requiring staff assistance to complete ADLs for 2 of 18 residents (R54, R32) reviewed for activities of daily living in the sample of 18.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure interventions to promote healing were in place to a non-pressure wound for 1 of 18 residents (R25) reviewed for quality of care in the sample of 18.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, interview, and record review the facility to prevent a decline in range of motion for 1 of 6 (R17) residents reviewed for range of motion in the sample of 18.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review the facility failed to transfer a resident safely. This applies to 1 of 18 residents (R69) reviewed for safety in the sample of 18.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure ongoing communication and collaboration with an outpatient dialysis center for 1 of 1 resident (R31) reviewed for dialysis services in the sample of 18.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received food that accommodated their food preferences and intolerances for 2 of 18 residents (R228, R26) reviewed for food preferences/intolerances in the sample of 18.
August 4, 2022Standard inspection · 8 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and record review the facility failed to identify areas of pressure, assess areas of pressure and implement interventions for pressure prevention. These failures resulted in deterioration of the pressure area for R22. These failures resulted in R43's pressure deteriorating into an unstageable pressure injury. These failures resulted in R178 developing a deep tissue injury. This applies to 3 of 8 residents (R22, R43, R178) in the sample of 19 reviewed for pressure.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was treated in a dignified manner for one of one resident (R178) reviewed for dignity in the sample of 19.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and record review the facility failed to shower a resident two times a week. This applies to one of three residents (R228) reviewed for activity of daily living (ADL)'s in the sample of 19.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, interview and record review, the facility failed to put interventions in place for a resident (R4) with hemiplegia and hemiparesis (muscle weakness or the inability to move on one side of the body that can affect the arms, legs and facial muscles) for 1 of 1 resident reviewed for range of motion in the sample of 19.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review the facility failed to prevent a resident fall, failed to assess a resident after a fall, and failed to transfer residents in a safe manner for two of ten residents (R178, R70) reviewed for safety in the sample of 19.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure appropriate incontinence care was given and failed to give incontinence care in a manner to prevent cross contamination for a resident with a history of urinary tract infection for 1 of 1 resident (R51) reviewed for incontinence care in a sample of 19.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, interview and record review the facility failed to check placement and residuals of a feeding tube prior to starting liquid nutrition for one of two residents (R15) reviewed for feeding tubes in the sample of 19.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility failed to remove gloves after providing incontinence care and failed to wear Personal Protective Equipment (PPE) as recommended. This applies to 3 of 4 residents (R22, R70, R56) reviewed for infection control in the sample of 19.
Fire safety inspections
32 fire safety citations on file: 7 on July 17, 2024, 11 on August 16, 2023, 14 on August 4, 2022.
Every fire safety citation32 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 17, 2024 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · July 17, 2024 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · July 17, 2024 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · July 17, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · July 17, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · July 17, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · July 17, 2024 · Corrected (the home has a date of correction)
- F
Have properly located and lighted "Exit" signs.
K 293 · August 16, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 16, 2023 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · August 16, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 16, 2023 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · August 16, 2023 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · August 16, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · August 16, 2023 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · August 16, 2023 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · August 16, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · August 16, 2023 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · August 16, 2023 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · August 4, 2022 · Corrected (the home has a date of correction)
- F
Have properly located and lighted "Exit" signs.
K 293 · August 4, 2022 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 4, 2022 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 4, 2022 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · August 4, 2022 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · August 4, 2022 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · August 4, 2022 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 4, 2022 · Corrected (the home has a date of correction)
- E
Install a two-hour-resistant firewall separation.
K 133 · August 4, 2022 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · August 4, 2022 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · August 4, 2022 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · August 4, 2022 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · August 4, 2022 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · August 4, 2022 · Corrected (the home has a date of correction)