201 East Falcon Highway, Flanagan, IL 61740 · Livingston County · (815) 796-2267
43 certified beds, about 37 residents a day · For profit - Corporation · Medicare and Medicaid since 1995
CMS Care Compare ratings, data as of September 1, 2026 · CCN 145842 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on May 8, 2024, inspectors cited 8 health deficiencies (the Illinois average is 12.6, the national average 9.2).
Of 52 health citations since June 2022, 8 were rated as actual harm or immediate jeopardy to residents.
CMS lists 1 fine totaling $31,327 in the last three years; the largest was $31,327, and the latest is dated July 29, 2025.
Nurses and nurse aides worked 2.94 hours per resident per day, against 3.45 across Illinois and 3.86 nationally. Registered nurses accounted for 1.06 of those hours.
20.8% of nursing staff left within the year CMS measured (Illinois average 44.5%).
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.
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 52 health citations on file.
Inspectors wroteBased on interview and record review the facility failed ensure a controlled medication was not stopped abruptly without notifying the physician for one of two residents (R1) reviewed for medication errors in the sample list of three. This failure resulted in R1 becoming unresponsive, falling, and being transferred to the hospital with benzodiazepine withdrawal, delirium, and syncope after R1's Ativan (benzodiazepine) was stopped abruptly.
Inspectors wroteBased on interview and record review the facility failed to ensure care plans included problems, goals, and interventions to address diagnoses and medication use for two of three residents (R2, R3) reviewed for medications in the sample list of three.
Inspectors wroteBased on interview and record review the facility failed to implement a bowel program for one of three residents (R3) reviewed for medications in the sample list of three.
Inspectors wroteBased on observation, interviews and record review the facility failed to address resident's care needs to obtain appointments in a timely manner, resulting in a delay in the removal of a gastrostomy feeding tube and a delay in podiatry services for an infection for (R15). R15 is one of three residents reviewed for infections/ medical devices in the sample list of 27. These delays resulted in R15's transfer to the local hospital, for antibiotic treatment of G-tube infection, and ingrown toenail infection.
Inspectors wroteBased on observation, interview and record review the facility failed to notify the physician in a timely manner of a delay in the removal of a gastrostomy feeding tube for (R15), a delay in podiatry services for infection for (R15) and a delay in the removal of an Internal Jugular (IJ), Peripherally Inserted Central Catheter (PICC) post the administration of antibiotics for (R30). R15 and R30 are two of three residents reviewed for infection/antibiotics/ surgically implanted devices in the sample list of 27.
Inspectors wroteBased on interview and record review the facility Social Services Director failed to conduct follow up visits following an abuse allegation for one resident (R3) of five residents reviewed for abuse from a sample list of five residents.
Inspectors wroteBased on interview and record review, the facility failed to safeguard and account for resident monies held in the resident trust fund cash box. This failure affects 19 residents (R2, R3, R5, R6, R8, R9, R10, R12, R13, R14, R16, R17, R19, R20, R21, R22, R23, R24, and R25) out of 25 reviewed for resident funds on the sample list of 25.
Inspectors wroteBased on interview and record review, the facility failed to convey resident funds to a resident's estate or probate within the required 30 days after death. This failure affects one resident (R7) out of 25 reviewed for resident funds on a sample list of 25.
Inspectors wroteBased on interview and record review the facility failed to protect the residents' right to be free from physical abuse by another resident. This failure affects three of seven residents (R1, R2, R5) reviewed for abuse in the sample of seven. Findings Include: The facility's Abuse Prevention and Prohibition Policy dated January 2024 documents the facility affirms the right of its residents to be free from abuse and free from mistreatment by anyone. Resident behaviors will be monitored for changes, which could trigger abusive behaviors. Resident to Resident abuse includes the term willful. The word willful means that the individual's action was deliberate regardless of whether the individual intended to inflict injury or harm. Physical abuse can include such things as hitting, slapping, punching, and kicking. [...]
Inspectors wroteBased on record review and interview the facility failed to ensure the facility's Medical Director and Director of Nursing attended Quality Assurance meetings. This failure has the potential to affect all 27 residents residing in the facility.
Inspectors wroteBased on interview and record review the facility failed to identify resident specific targeted behaviors and implement nonpharmacological interventions prior to the use and increase of psychotropic medications for two (R1, R19) of five residents reviewed for psychotropic medications on the sample list of 23 residents. Findings Include: 1. R1's electronic health record documents current orders for Geodon (Antipsychotic) Hydrochloride 60 milligrams (mg)by mouth twice a day and Sertraline (antidepressant) Hydrochloride 100 MG (Sertraline HCl) by mouth one time a day. R1's medical record does not contain resident specific targeted behavior or resident specific interventions or response to interventions. Though the facility did utilize a preprinted behavior tracking. the behaviors/interventions listed were not specific to R1. [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions and failed to perform hand hygiene during incontinence care for four (R8, R9, R1 and R24) of 16 residents reviewed for infection control on the sample list of 23.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the call light was within reach for one of 12 residents (R13) reviewed for call lights on the sample list of 23. Findings Include: On 5/06/24 at 1:20 PM, R13 was sitting up in the reclining chair in R13's room in front of the television. R13's call light was stretched all the way to the middle of the room and tied to a water jug on the over bed table, which is next to the back of R13's chair. The water jug was on the far end of the table, out of R13's reach. R13 attempted to reach the call light and was not able to. On 5/06/24 at 1:26 PM, V10 CNA (Certified Nursing Assistant) entered R13's room and confirmed that R13 was not able to reach the call light and stated, I wonder why (R13) is like that. R13 care plan dated 3/18/24 documents R13 has impaired physical mobility. [...]
Inspectors wroteBased on interview and record review the facility failed to provide quarterly statements for one (R9) of sixteen residents reviewed for resident funds on the sample list of 23.
Inspectors wroteBased on record review and interview the facility failed to update the physician on significant weight changes for one of one resident (R29) reviewed for weight changes on the sample list of 23. Findings Include: R29's MDS (Minimum Data Set) assessment dated [DATE] documents R29 is alert and oriented. On 5/06/24 at 9:37 AM, R29 stated R29 has not had any weight changes that R29 is aware of. R29's ongoing weight log documents the following weights: [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to administer medications in accordance with physician orders and manufacturer's instructions for three (R8, R2, and R11) residents reviewed for medication administration in the sample list of 23. The facility had four medication errors out of 28 opportunities resulting in a 14.28% medication error rate.
Inspectors wroteBased on observation, interview, and record review, the facility failed to allow a hospitalized resident to return to the facility. This failure affects one resident (R1) out of 5 reviewed for transfers and discharges in the sample of 5.
Inspectors wroteBased on interview and record review, the facility failed to treat residents with respect, dignity and provide care in a manner that promotes quality of life by not allowing a resident to have a say in medical treatment for one of four residents (R3) reviewed for respiratory care in the sample of six. This failure resulted in R3 being fearful of staff and experiencing ongoing psychosocial harm of R3; which resulted in R3 being sent to the emergency room for an anxiety attack. Findings Include: R3's MDS (Minimum Data Set) dated 12/24/24 documents R3 is alert and oriented. R3's January 2023 Physician Orders document the following orders: oxygen at 2-5 L (liters) per NC (Nasal Cannula) or vented mask, and BiPAP (BiLevel Positive Airway Pressure) with 6 LPM (liters per minute) oxygen bled into it. R3's ongoing diagnoses list includes the following diagnoses: [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to notify the physician of a pressure ulcer to obtain an appropriate wound treatment, assess and document the pressure ulcer, notify the resident representative of a pressure ulcer and prevent cross contamination of the wound during a treatment for one of three residents (R2) reviewed for wounds in the sample list of six. This failure resulted in R2's MASD (Moisture Associated Skin Damage) progressing to an unstageable pressure ulcer. Findings Include: R2's ongoing diagnoses listing documents R2 has TBI (Traumatic Brain Injury), Morbid Obesity, and Hemiplegia and Hemiparesis following unspecified Cerebrovascular Disease affecting Right Dominant Side. On 1/22/23 at 11:22 am, V10 (R2's POA (Power of Attorney) stated R2 was at the hospital on 1/21/23 and the nurse there said R2 has an open area on R2's buttocks. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician orders for respiratory care including oxygen, BiPAP and C-PAP usage, change oxygen tubing and humidifier bottles as ordered and document resident complaisance/non-compliance of respiratory care for four of four residents (R1, R2, R3, R4) reviewed for respiratory care in the sample list of six. This failure resulted in psychosocial harm of R3. R3 was sent to the hospital after having a panic attack and remains fearful of facility staff's action related to R3's respiratory care. Findings Include: 1. R3's January 2023 Physician Orders document the following orders: oxygen at 2-5 L (liters) per NC (Nasal Cannula) or vented mask, change oxygen tubing and humidifier once a week (scheduled for Sundays), and BiPAP (BiLevel Positive Airway Pressure) with 6 LPM (liters per minute) oxygen bled into it. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to have a nurse serving as Director of Nursing (DON.) This failure has the potential to affect all 30 residents residing at the facility. Findings Include: On 1/22/24 from 8:00 am - 4:30 pm and 7:00 pm - 11:00 pm, there was no nurse working as the DON (Director of Nursing). At 2:55 pm, V4 LPN (Licensed Practical Nurse) stated the facility does not have a DON and that V4 is the only facility nurse therefore there is no guidance being provided for nursing staff. On 1/23/24 from 9:00 am - 4:30 pm there was no nurse working as the DON. On 1/23/24 at 3:30 pm, V1 AIT (Administrator in Training) stated the facility has not had a DON since February 15, 2022. The Facility assessment dated [DATE] documents the facility will employee other nursing personnel; those with administrative duties for 8-16 hours a day. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the facility in a safe, structurally intact, environment. This failure has the potential to affect all 30 residents residing at the facility. Findings Include: On 1/22/24 at 8:40 am, the bottom of the hallway wall outside of the shower room was crumbled, approximately 6 inches up off the floor and 4 feet long. There were large chunks of a concrete looking substance lying on the floor, in the hallway, under a shower bed that was pushed up against the wall. At this time, V4 LPN (Licensed Practical Nurse) stated V4 started working at the facility in November 2023 and noticed the wall crumbling in December 2023. At this time, V26 CNA (Certified Nursing Assistant) stated V26 has worked at the facility for 3.5-4 years and that the wall has been like that a long time, 6-12 months. [...]
Inspectors wroteBased on interview and record review, the facility failed to protect a resident from potential further abuse during an abuse investigation for one of four residents (R3) reviewed for respiratory care in the sample list of six. Findings Include: R3's MDS dated [DATE] documents R3 is alert and oriented. On 1/22/24 at 7:30 pm, R3 stated V6 had turned R3's oxygen up too high last week and would not listen to R3 about turning it down so V5 CNA (Certified Nursing Assistant) ended up reporting it to V1 AIT (Administrator in Training). R3 stated R3 is still waiting to talk to V1 about it. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to complete wound assessments, complete wound treatments as ordered, perform hand hygiene to prevent cross contamination of the wound, and notify the physician of not having treatment supplies for two of three residents (R5, R6) reviewed for wounds in the sample list of six. Findings Include: The facility's Skin Condition Monitoring Policy dated January 2002 documents upon notification of a skin lesion, wound, stasis ulcer, or other skin abnormality, the charge nurse will assess and document the findings. Any skin abnormality will have a specific treatment order for frequency. Documentation of the skin abnormality must occur upon identification and at least weekly thereafter until the area is healed. Documentation of the area must include the following: characteristic: [...]
Inspectors wroteBased on interview and record review, the facility failed to maintain a complete and accurate medical record for one of four residents (R3) reviewed for respiratory care in the sample list of six. Findings Include: On 1/22/24 at 7:30 pm, R3 stated over the weekend, R3 was short of breath and had called for the nurse, V6 Agency RN (Registered Nurse) to give R3 a breathing treatment. R3 stated when V6 entered R3's room, V6 cranked R3's oxygen level up to 10 L/NC. R3 stated this has actually happened twice now. On 1/22/24 at 8:05 pm, V5 CNA confirmed R3 had an episode on 1/18/24 and again on 1/20/24 where R3 was in respiratory distress; very short of breath and requesting a PRN (as needed) nebulizer treatment. V5 stated that V6 Agency RN (Registered Nurse) ended up turning R3's oxygen up to 10 L (liters) per nasal cannula, and giving R3 an inhaler along with the nebulizer. [...]
Inspectors wroteBased on interview and record review, the facility failed to employ a Director of Nursing. This failure has the potential to affect all 32 residents in the facility. Findings Include: On 10/24/23 at 10:45am, V1 Administrator in Training (AIT) confirmed the facility does not have a DON. V1 stated V1 has scheduled multiple DON interviews but the person cancels or does not show up. V1 stated the facility has not had a DON for almost two years. On 10/24/23 at 10:49am, V4 Certified Nursing Assistant stated the facility does not have a DON. The facility Resident Room and Bed Roster dated 10/24/23 documents 32 residents reside at the facility.
Inspectors wroteBased on observation, interview and record review, the facility failed to protect the residents right to be free from mental and verbal abuse by a staff member for one of five residents (R10) reviewed for abuse in the sample list of 11. This failure resulted in psychosocial harm for R10 as evidenced by R10 being tearful and shaking while talking about the abuse three days later and R10 being fearful of retaliation from the staff member for reporting the abuse. Findings Include: The facility's Abuse Prevention Program dated 11/28/16 documents this facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This facility is committed to protecting our residents from abuse by anyone including; [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services of a Registered Nurse for at least eight consecutive hours a day, seven days a week and failed to have a Director of Nursing. This failure has the potential to affect all 36 residents who reside at the facility. Findings Include: On 9/2/23 at 8:20 am, R1 stated the facility has not had a DON (Director of Nursing) since R1 was admitted to the facility, therefore if R1 has a problem with cares, there isn't anyone to take R1's concerns to and nobody to hold the staff accountable, it's a free for all. On 9/2/23 from 8:20 am - 1:00 pm, there was no DON in the facility or an RN (Registered Nurse) working the floor. On 9/2/23 at 1:10 pm, V1 AIT (Administrator in Training) stated the facility does not have a DON and hasn't since February 2022, 19 months ago. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a comfortable sound level for three of four residents (R6, R7, and R9) reviewed for homelike environment in the sample list of 11. Findings Include: On 9/2/23 at 9:25 am, V12 (R7's family) stated that R6, R7's roommate plays the music too loud giving R6 a headache. V12 explained R7 likes music but when R7 is trying to rest and the music is loud, R7 can't. The facility staff have told R6 to turn it down which R6 will do but as soon as the staff leave the room, R6 turns it back up. V12 stated, V12 knows it's R6's right to listen to the music but what about R7's rights? Nothing is being done about it. R6's Progress Notes dated 7/18/23 document V4 SSD (Social Service Director) discussed R6's stereo with V11 (R6's family). The stereo volume control does not work, and it only plays loud. [...]
Inspectors wroteA. Based on observation, interview and record review, the facility failed to assess a surgical wound weekly, complete dressing changes as ordered to prevent a surgical wound from deteriorating, failed to notify the physician/wound practitioner of the wound decline and failed to implement nutritional interventions for wound healing for one of one residents (R32) reviewed for surgical wounds on the sample list of 17. This failure resulted in delayed wound healing and R32's surgical wound increasing in size. B. Based on observation, interview and record review, the facility failed to apply a splint/brace as ordered for one of two residents (R19) reviewed for splints/braces on the sample list of 17. Findings Include: A.) On 7/16/23 at 8:45 AM, R32 stated R32 has a foot wound on R32's right foot caused by a screw that R32 stepped on at R32's house. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to prevent the development of a deep tissue injury pressure wound, failed to notify the physician and/or wound practitioner of a newly developed deep tissue injury and obtain treatment orders and document the deep tissue injury for one of two residents (R32) reviewed for pressure injuries on the sample list of 17. This failure resulted in R32 developing a new deep tissue injury to the plantar surface of the right foot. Findings Include: The facility Decubitus Care/Pressure Areas Policy dated January 2018 documents it is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcers. [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to employ a Registered Nurse to serve as Director of Nurses and failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week. This failure has the potential to affect all 36 residents in the facility. Findings Include: On 7/16/23, 7/17/23, 7/18/23, and 7/19/23 there was no Director of Nurses present in the facility. On 7/18/23 at 3:50 PM V1 Administrator confirmed the facility did not have eight hours of Registered Nurse coverage every day, 7 days a week during the time frame reviewed. V1 also confirmed the facility's average daily census was around its current census of 36 residents. V1 also confirmed the facility has not employed a Registered Nurse to serve as Director of Nurses since February of 2022. [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to have a governing body in which the facility failed to have a licensed Administrator managing the facility. This failure has the potential to affect all 36 residents residing in the facility. Findings Include: Upon survey entrance and throughout the survey (7/16/23-7/19/23) there was no licensed administrator managing the facility. On 7/17/23 at 2:10 PM V1 AIT (Administrator in Training) stated V1 applied for her temporary Administrator's license two weeks ago but has not received it yet. V1 stated that the previous administrator left the building in January of 2023, and it was at that time that V1 took over the role of AIT. [...]
Inspectors wroteBased on interview and record review, the facility failed to develop a thorough and complete Quality Assurance and Performance Improvement (QAPI) Program, failed to sustain the QAPI program during transitions in leadership, and failed to implement the QAPI Program by failing to identify and prioritize problems and make good faith attempts to address those problems. This failure has the potential to affect all 36 residents in the facility. Findings Include: On 7/17/23 at 2:10 PM V1 Administrator in Training (AIT) confirmed the facility has not been implementing a complete QAPI program and V1 stated she is not sure exactly sure what all the QAPI program entails. V1 stated she took over the building as AIT in January 2023 and the facility has not held a Quality Assurance and Performance Improvement meeting since she took over. [...]
Inspectors wroteBased on interview and record review, the facility failed to develop a thorough and complete Quality Assessment and Assurance (QAA) of Policies and Procedures and a Quality Assurance and Performance Improvement (QAPI) Program and failed to implement the QAA and QAPI Programs by failing to identifying quality deficiencies, develop and implement appropriate plans of action to correct such deficiencies, regularly review and analyze data, act on available data to make improvements, conduct distinct Performance Improvement Projects (PIPs), and implement corrective actions and mechanisms that include feedback and learning throughout the facility. This failure has the potential to affect all 36 residents in the facility. Findings Include: [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure the required quarterly Quality Assessment and Assurance (QAA) committee meetings were completed and failed to ensure the Director of Nurses and Infection Preventionist were members of the QAA Team and attended QAA meetings. This failure has the potential to affect all 36 residents in the facility. Findings Include: On 7/17/23 at 11:00 AM V1 Administrator in Training provided two QAA Meeting Sign-in Sheets for the previous year's QAA meetings. One was dated 9/21/22 and the other was dated 11/30/22. On 7/17/23 at 2:10 PM V1 Administrator in Training confirmed the facility only held two QAA meetings over the last year and had not held a QAA meeting at all in the year 2023. V1 stated they have not had a QAA meeting since November 2022. [...]
Inspectors wroteBased on interview and record review the facility failed to conduct infection control surveillance. This failure has the potential to affect all 36 residents in the facility. Findings Include: On 7/17/23 at 2:10 PM V1 Administrator in Training confirmed the facility has not kept an updated infection control surveillance log since March of 2023. The Infection Control Policy dated 3/8/23 documents the facility will keep an updated infection control log on a daily basis in order to analyze data and identify trends that would indicate need for additional controls to prevent any further spread of infection. The responsibility to maintain these records of surveillance and monitoring will be the Director of Nurses, Infection Preventionist, or Administrators. [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to designate an onsite qualified Infection Preventionist who works at least part time in the facility. This failure has the potential to effect all 36 residents in the facility. Findings Include: Upon survey entrance and throughout the survey (7/16/23-7/19/23) there was no Infection Preventionist in the facility. On 7/17/23 at 2:10 PM V1 Administrator in Training confirmed the facility has not had an onsite Infection Preventionist in the building since October 2022. V1 stated V24 Regional Nurse has been filling in but has not been in the building for a couple weeks and is now off with an injury. [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to initial and date oxygen and nebulizer tubing, and humidity bottles; and failed to keep respiratory items covered when not in use for five of five residents (R6, R8, R17, R22, R29) reviewed for respiratory care on the sample list of 17. Findings Include: 1. R8's undated Face Sheet documents R8's diagnoses as Chronic Obstructive Pulmonary Disease (COPD), Obstructive Sleep Apnea, COPD with acute exacerbation, Chronic Respiratory Failure with Hypoxia, Anxiety Disorder. R8's Physicians Order Sheet (POS) dated 7/18/23 documents an order for Oxygen at 3L (liters)/minute via nasal cannula every shift related to Chronic Respiratory Failure, keep sats (saturation) 88% - 92%; Oxygen tubing and humidifier change every Saturday night shift; [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a homelike environment for one of two residents (R17) reviewed for homelike environment on the sample list of 17. Findings Include: On 7/17/23 at 4:02 PM, R17 was lying in bed and a large hole was noted in the wall behind R17's bed, approximately 2 feet by 5 inches. V20 (R17's Family), who was at the bedside, stated the hole in the wall has been there for months. V20 reported that staff told V20 that the hole was caused from the bed hitting the wall when they reposition R17 in bed. On 7/18/23 at 9:16 AM, V6 Maintenance Supervisor stated V6 was aware of the hole in the wall but was not aware that it had gotten as big as it is and that you can literally knock on the wall of the other room through it. V6 stated things like this should be reported to V6 and placed in the Work Order Book. [...]
Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a bed hold notice to two of two residents (R6, R16) reviewed for hospitalization on the sample list of 17. Findings Include: 1) R6's MDS (Minimum Data Set) dated 6/13/23 documents that R6 is alert and oriented. On 7/16/23 at 9:39 AM, R6 stated R6 was sent to the hospital last night (7/15/23) for chest pain and returned to the facility. R6 stated R6 was not given a bed hold notice at that time. R6's Progress Notes dated 7/15/23 does not document that a bed hold notice was provided to R6. On 7/16/23 at 3:27 PM, R6 was not in R6's room. At this time, V2 RN (Registered Nurse) stated that R6 was sent back to the hospital this afternoon for breathing issues. On 7/16/23 at 3:37 PM, V2 RN stated V2 did not give a bed hold notice to R6 today when V2 sent R6 out to the hospital. [...]
Inspectors wroteBased on observations, interviews, and record review, the facility failed to complete the Minimum Data Set to accurately reflect the needs of two of two residents (R16, R19) reviewed for accurate MDS's on the sample list of 17. Findings Include: 1) On 7/17/23 at 8:35 AM, R16's bed had bilateral half siderails in the elevated position at the head of the bed. R16's Restraint-Enabler Evaluation dated 6/29/23 documents two upper half siderails are used for bed mobility and are not a restraint. R16's MDS (Minimum Data Set) dated 7/2/23 documents R16 uses siderail restraints daily. On 7/17/23 at 12:34 PM, V7 MDS/Care Plan Coordinator stated R16 does not use a restraint but does use half upper side rails to help R16 turn and reposition and steady R16's self when getting up out of bed and getting into bed. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive care plan to accurately reflect resident needs for two of 17 residents (R15, R16) reviewed for care plans on the sample list of 17. Findings Include: The facility Comprehensive Care Planning Policy revised 7/20/22 documents it is the policy of this facility to comprehensively assess and periodically reassess each resident admitted to this facility. It is to be noted that the care plan is for planning care and services. A comprehensive care plan shall be developed within seven days of the completion of the RAI (Resident Assessment Instrument). The care plan contains pertinent information about the resident including a summary listing of healthcare information such as physician orders, dietary orders, therapy services, and social services. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to properly secure an oxygen cylinder and investigate a fall for two of two residents (R17, R4) reviewed for accident hazards on the sample list of 17. Findings Include: 1) On 7/16/23 at 9:47 AM, R17 was lying in bed with oxygen running at 2.5 liters per nasal cannula from an oxygen concentrator. There was a small portable oxygen cylinder sitting on the floor, without a stand or secured, behind the privacy curtain. On 7/18/23 at 12:03 PM, V7 MDS (Minimum Data Set)/Care Plan Coordinator stated portable oxygen cylinders should be stored in the oxygen room, and in racks. The oxygen cylinder in R17's room should have been secured in the back of R17's wheelchair, in the oxygen holder. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications according to Physician Orders and follow Manufacturer's Recommendations for medication administration for two of four residents (R4, R11) reviewed for medication administration on the sample list of 17. The facility had four errors out of 26 opportunities for a medication error rate of 15.38%. Findings Include: 1) R11's July 2023 Physician Orders document orders that include the following: Metformin {Anti-diabetic} 1,000 mg (milligrams) one tablet BID (twice a day) and NovoLog Flex Pen with instructions to inject 15 units subcutaneously BID for type II Diabetes Mellitus in addition to sliding scale dose and inject as per sliding scale: if blood glucose level is 180 - 200 give 4 units, if 201 - 250 give 5 units, 251 - 300 give 6 units, 301 - 350 give 7 units, 351 - 500 give 10 units. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to maintain accurate and complete medical records for two (R16, R4) of two residents reviewed for complete medical records on the sample list of 17. Findings Include: 1) On 7/16/23 at 9:11 AM, R16 was propelling R16's self down the hallway in a wheelchair wearing a brace to the right lower extremity, which kept R16's leg fully extended. At this time, V2 RN (Registered Nurse) stated R16 has worn the brace for as long as V2 can remember. On 7/17/23 at 8:31 AM, R16 was propelling R16's self down hall in a wheelchair wearing a brace to the right lower extremity. R16's July 2023 Physician Order Sheets do not document an order for a brace. [...]
Inspectors wroteBased on record review and interview, the facility failed to designate a Registered Nurse to serve as a full time Director of Nursing. This failure effects all 25 residents residing in the facility.
Inspectors wroteBased on interview and record review, the facility failed to flush a Peripherally Inserted Central Catheter (PICC) according to the doctor's orders, for one resident (R14) of one resident reviewed for PICC line flushes on the sample list of 18.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain oxygen administration equipment in a sanitary manner, failed to date oxygen tubing according to facility policy, and failed to develop their policy to address sanitary storage of oxygen tubing when not in use. This failure effects one resident (R7) out of one reviewed for oxygen and respiratory care on the sample list of 18.
19 fire safety citations on file: 5 on May 8, 2024, 9 on July 19, 2023, 5 on June 9, 2022.
| Date | Penalty | Amount or length |
|---|---|---|
| July 29, 2025 | Payment Denial | 4 days from October 24, 2025 |
| January 24, 2024 | Fine | $31,327 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Illinois | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 2.94 | 3.45 | 3.86 |
| Registered nurses | 1.06 | 0.72 | 0.69 |
| All nursing staff on weekends | 2.62 | 3.07 | 3.42 |
| Nurse aides | 1.88 | ||
| Licensed practical nurses | 0.00 | ||
| Nursing staff turnover (share who left in a year) | 20.8% | 44.5% | 45.8% |
| Registered nurse turnover | 14.3% | 41.8% | 42.9% |
| Administrators who left | 1 |
CMS expects 5.17 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.07 on weekdays and 2.62 on weekends, 15% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.1% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.69 in April to June 2025 to 2.94 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 2.94 | 1.06 | 3.07 | 2.62 | 0.1% | 0 of 90 | 37 |
| Oct to Dec 2025 | 3.42 | 1.35 | 3.63 | 2.92 | 0.5% | 0 of 92 | 31 |
| Jul to Sep 2025 | 3.98 | 1.56 | 4.21 | 3.39 | 0.0% | 0 of 92 | 28 |
| Apr to Jun 2025 | 3.69 | 1.32 | 3.93 | 3.10 | 0.0% | 0 of 91 | 30 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Illinois, Jan to Mar 2026 | 3.26 | 0.65 | 3.40 | 2.92 | 5.4% | 0.6% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Illinois, all employers | |||
| CNAs (nursing assistants) | $22.10 | $18.95 to $23.26 | 68,640 |
| LPNs and LVNs | $36.06 | $30.57 to $38.25 | 17,440 |
| Registered nurses | $46.15 | $38.47 to $50.94 | 138,910 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Illinois | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 27.2 | 13.4 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.9 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.0 | 1.5 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 1.9 | 3.1 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.9 | 2.2 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 21.6 | 14.3 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 5.8 | 4.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 1.2 | 21.7 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 18.2 | 26.1 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 12.8 | 13.8 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.4 | 2.0 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.1 | 2.2 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Flanagan Rehabilitation and Health Care Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (43.2% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
43.2% this home
No different from the national rate
US median of homes 51.5% · Illinois: 106 better, 85 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 26 eligible stays.
9.9% this home
No different from the national rate
US median of homes 10.7% · Illinois: 2 better, 14 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 35 eligible stays.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
US median of homes 7.1% · Illinois: 3 better, 10 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 14 eligible stays.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Illinois50.0% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 10 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Illinois0.3% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 12 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Illinois1.5% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 12 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Illinois100.0% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 4 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: Legal Business Name Not Available.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Ownership data not available |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
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