2220 State Street, Pekin, IL 61554 · Tazewell County · (309) 347-1110
202 certified beds, about 89 residents a day · For profit - Corporation · Medicare and Medicaid since 1974
CMS Care Compare ratings, data as of September 1, 2026 · CCN 145275 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on August 7, 2024, inspectors cited 13 health deficiencies (the Illinois average is 12.6, the national average 9.2).
Of 71 health citations since October 2022, 13 were rated as actual harm or immediate jeopardy to residents (2 immediate jeopardy).
CMS lists 7 fines totaling $260,624 in the last three years; the largest was $64,120, and the latest is dated March 28, 2026.
Nurses and nurse aides worked 3.42 hours per resident per day, against 3.45 across Illinois and 3.86 nationally. Registered nurses accounted for 0.20 of those hours.
65.9% 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 71 health citations on file.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide continuous observation for two of two residents (R4, R8) that are at high risk for falls and require continuous monitoring, in a sample of 10. These failures resulted in R4 having an unwitnessed fall which required R4 to be transferred to the hospital emergency room for evaluation and was diagnosed with Acute Cystitis with Hematuria, Urinary Tract Infection, Post Traumatic Contusion, Edema of Left Frontal Scalp (Hematoma) and Left Hip Pain. The following days, R4 was reported to be lethargic, had slurred speech, was leaning left, hallucinating, required more assistance with activities of daily living and went on hospice on 7/17/26, 6 days post fall.
Inspectors wroteBased on interview and record review the facility failed to document a discharge summary and/or a recapitulation of stay for one resident (R1) of three residents reviewed for discharge. R1's Medical Record documents that he was admitted to the facility with diagnosis to include but not limited to Anemia post hemorrhage, Chronic Obstructive Pulmonary Disease and Congestive Heart Failure. R1's Medical Record contain a Release of Responsibility form dated 6/26/26 and signed by R1. The form documents R1 was educated to wait to see the doctor for discharge orders and R1 did not want to. R1's Medical Record does not contain any other documentation regarding R1's discharge against medical advice. On 7/28/26 R1 stated that no one discussed discharge instructions, safety or any other information before he left the facility. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician-ordered rehabilitation services were implemented and monitored for one (R1) of three residents reviewed for rehabilitation services in the sample list of five. This failure resulted in R1 not receiving ordered rehabilitation services from admission through the time of survey, placing R1 at risk for avoidable functional decline and causing R1 to express fear, anxiety and depression.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with impaired skin integrity received ongoing wound assessment, physician oversight, implementation of ordered treatment, and care planning for one (R5) of three residents reviewed for skin integrity in the sample list of five.
Inspectors wroteBased on interview and record review the facility failed to respond to resident call lights in a timely manner for five of ten residents (R4, R5, R8, R9 and R10) reviewed for call light response in a sample of 13.
Inspectors wroteBased on observation, interview and record review the facility failed to provide hydration services (fresh water) for three of ten residents (R5, R9 and R10) reviewed for hydration in a sample of 13.
Inspectors wroteBased on observation, interview and record review the facility failed to maintain adequate laundry services due to department staffing shortages, resulting in delayed clothing returns and a lack of available personal clothing for residents. This failure has the potential to affect all 89 residents residing within the facility.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the facility maintained an effective pest control program. This has the potential to affect all 89 residents.
Inspectors wroteBased on interview record review and observation the facility failed to provide appetizing or appealing-appearing food and appropriate condiments for residents of the facility. This failure has the potential to affect all 94 residents currently residing in the facility.
Inspectors wroteBased on interview, observation and record review the facility failed to provide assistance with personal hygiene cares for one resident (R1) of 4 residents reviewed for Activities of Daily Living in the sample of 11.
Inspectors wroteBased on record review, interview and observation the facility failed to provide physician-ordered medication for one resident (R1) of six residents reviewed for medication administration in the sample of 11.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure baseboard heaters were maintained in a safe manner and failed to implement an effective system to monitor heater surface temperatures and resident room arrangements, including bed placement, to prevent burn hazards and potential fire risks. These deficient practices resulted in R1 becoming entrapped between the bed and a baseboard heater, sustaining painful partial-thickness burns with blistering to the left upper arm, left forearm, and left hand that required emergency room treatment. These deficient practices had the potential to affect all 87 residents residing in the facility. These failures resulted in Immediate Jeopardy. [...]
Inspectors wroteBased on record review and interview the facility failed to provide QAPI (Quality Assurance and Performance Improvement) training to all employees. This failure has the potential to affect all 87 residents residing within the facility.
Inspectors wroteBased on interview and record review, the facility failed to perform pressure ulcer care and skin checks as ordered for one of three residents (R1) reviewed for pressure ulcer care in a sample of four. The facility's Pressure Injury Assessment and Treatment policy, dated 12/2024, documents to document in the resident electronic medical record when the treatment is completed. On 12/4/25, R1 stated that his wound care varies as to when it is completed. R1 stated that the wound care is done at least daily. R1's Treatment Administration Record, dated 11/12/25 through 12/4/25, documents to cleanse R1's left heel with soap and water. Apply Dakins (antiseptic) soaked gauze to the wound bed and cover with an abdominal pad, and cover with a gauze wrap and apply heel boots every day shift. [...]
Inspectors wroteBased on interview and record review the facility failed to perform nephrostomy care, urinary catheter care, and document urinary output as ordered for one of two residents (R1) reviewed for bowel and bladder in a sample of four.
Inspectors wroteBased on Interview and Record review, the facility failed to notify a resident's physician of new onset, unilateral extremity pain for a resident with severe cognitive impairment for one of three residents (R1) reviewed for injury in the sample of four. This failure resulted in R1 waiting over 24 hours to receive emergency care/ imaging for a fracture of R1's right tibia and fibula.
Inspectors wroteBased on Observation, Interview and Record Review, the facility failed to ensure that direct resident care staffing was adequate to meet the needs of residents in the facility. This failure has the potential to affect all 83 residents residing in the facility.
Inspectors wroteBased on interview and record review, the facility failed to assess and document a resident's pain and administer pain medication to a resident with severe cognitive impairment, who was later diagnosed with right lower leg fractures for one of three residents (R1) reviewed for accidents in the sample of four.
Inspectors wroteBased on interview and record review, the facility failed to protect a resident (R2) from physical abuse by another resident (R1), reviewed for abuse, in a sample of seven. Based on interview and record review, the facility failed to protect a resident (R2) from physical abuse by another resident (R1), reviewed for abuse, in a sample of seven.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident rooms were clean and free of urine odor, resident room windows had privacy blinds or curtains in good repair, resident heating units were properly attached to the wall, and failed to ensure all resident rooms had adequate cooling for five of 18 residents (R4, R7, R9, R38 and R68) reviewed for homelike environment in the sample list of 40.
Inspectors wroteBased on interview and record review, the facility failed to prevent abuse for one resident (R2) reviewed for abuse in a sample of six.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents consumed their medications for five residents (R1, R2, R3, R5 and R7) and the facility failed to have a physician's order for medication administered for one resident (R7) of 8 residents reviewed for medication administration. Findings Include: The Facility's Medication Administration policy dated 12/16/24 documents, Drug administration shall be defined as an act in which a single dose of a prescribed drug or biological is given to a resident by an authorized person in accordance with all laws and regulations governing such acts. [...]
Inspectors wroteBased on observation, interview and record review the facility failed to properly store medications for 2 residents (R6 and R8) of seven residents reviewed for medication pass in a total sample of 8. Findings Include: The Facility's Procurement and Storage of Medication policy reviewed 12/16/24 documents, All medications, except those requiring refrigeration, shall be kept in the locked medicine room or locked medication cart. On 4/2/25 at 10:05 AM there were two albuterol inhalers each with over 100 doses left on R6's bedside table. The inhalers did not have any label on them with name or date dispensed. There was no one in the room. On 4/2/25 at 10:10 AM V5 (Licensed Practical Nurse) confirmed there were two albuterol inhalers on R6's bedside table. V5 stated R6 did not have an order for the albuterol inhaler. V5 stated, (R6) used to have an order for the inhalers. [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident safety during van transportation for one (R1) of three residents reviewed for accidents in a sample of five. This failure resulted in R1 sustaining a fall and suffering from pain and fractured ribs.
Inspectors wroteBased on interview and record review the facility failed to ensure one resident (R1) was free from misappropriation of funds of three residents reviewed for abuse. Findings Include: The Facility's Abuse Prevention Program dated 11/28/2016 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 includes, but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. [...]
Inspectors wroteBased on Observation, Interview and Record review, the facility failed to complete physician ordered wound treatments daily for one of three residents (R1) reviewed for Wound Care in the sample of three. Finding Include: The facility's Health Care Decubitus Care/Pressure Areas policy, dated 1/2018, 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 ulcer. Complete all areas of the Treatment Administration Record or Wound Documentation Record. Initiate physician order on the treatment sheet. Documentation of the pressure area must occur upon identification and at least once each week on the TAR (Treatment Administration Record) or Wound Documentation Form. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to follow Enhanced barrier precautions while performing wound care and follow hand hygiene for one of three residents (R1) reviewed for Wound Care, and Infection Control in a sample of three.
Inspectors wroteBased on interview and record review, the facility failed to assess a wound and promptly initiate treatment upon identification of pressure ulcer for one of three residents (R2) reviewed for pressure ulcer wound treatment in the sample of eleven. This failure resulted in R2's pressure ulcer worsening to Unstageable.
Inspectors wroteBased on observation, record review and interview the facility failed to ensure enhanced barrier precautions and/or contact precautions were in place for six (R5, R8, R13, R16, R38, R43) of six residents reviewed for Infection Control) in the sample of 37. This failure has the potential to affect all 90 residents who currently reside in the facility.
Inspectors wroteBased on record review and interview the facility failed to monitor active infections in the facility and failed to implement their Antibiotic Stewardship Program. These failures have the potential to affect all 90 residents who currently reside in the facility.
Inspectors wroteBased on interview and record review the facility failed to issue a written Notification of Hospital Transfer upon Discharge for four (R38, R41, R51 and R61) of four Residents reviewed for hospitalization in the sample of 37.
Inspectors wroteBased on observation, interview and record review the facility failed to develop a comprehensive person-centered care plan for eight of 19 residents (R16, R17, R21, R28, R33, R41, R43, R63) reviewed for care plans in the sample of 36.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure physician orders were obtained, oxygen tubing and humidifier bottles were changed routinely and dated, oxygen signs were posted, and oxygen cylinders were stored safely for seven (R17, R28, R33, R38, R41, R48, R51) of seven residents reviewed for oxygen in a sample of 37.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident Minimum Data Set/MDS Resident Assessments were completed correctly for two (R16 and R17) of two residents in a sample of 37.
Inspectors wroteBased on interview and record review, the facility failed to ensure a PASRR (Preadmission Screening and Resident Review) Level II screening for mental disorder was completed for one (R66) of one resident reviewed for PASRRs in a sample of 37.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident Baseline Care plan includes oxygen for one (R28) of 19 residents reviewed for Care plans in a sample of 37.
Inspectors wroteBased on observation, interview, and record review the facility failed to revise resident Care Plans to reflect resident condition for three (R38, R41, and R43) of 19 residents reviewed for Care Planning in the sample of 37.
Inspectors wroteBased on observation, interview, and record review the facility failed to assess and monitor pressure ulcers weekly and failed to perform hand hygiene in between glove changes for one (R16) of four residents reviewed for pressure ulcers in the sample of 37.
Inspectors wroteBased on observation, interview, and record review the facility failed to investigate a resident fall and conduct a root cause analysis for one (R48) of two residents reviewed for falls in the sample of 37.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Registered Dietician recommendations were communicated to the Physician and failed to document daily weights on the Medication Administration Records for two (R41 and R48) of five residents reviewed for nutrition in the sample of 37.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide gastrostomy feeding per order and provide gastrostomy tube care for one (R43) of two residents reviewed for enteral feedings in the sample of 37.
Inspectors wroteBased on interview and record review, the facility failed to ensure medications were not left at residents' bedside for one (R17) of 19 residents reviewed for medication storage in a sample of 37.
Inspectors wroteBased on observation, interview and record review, the facility failed to prevent a resident with known wandering and exit seeking behaviors from leaving the facility without staff supervision for one of four residents (R1) reviewed for elopement in a sample of four. R1 was last seen by staff in the facility on 7/13/24 at 6:00 pm and was located three days later (7/16/24) on a local park bench, approximately two and a half miles from the facility, in 90-degree Fahrenheit temperature. This failure resulted in R1 requiring transportation to the local hospital for evaluation and treatment. This failure has the potential to affect all Elopement Risk Residents residing in the facility.
Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive person-centered Care Plan for one (R1) of four residents reviewed for Care Plans in a sample of four.
Inspectors wroteBased on interview and record review the Facility failed to prevent accidents/falls with injury for one of three residents (R1) reviewed for accidents. This failure resulted in R1 requiring hospital evaluation and treatment for injuries and a decline in Activities of Daily Living (R1).
Inspectors wroteBased on observation, interview and record review the Facility failed to supply Physician ordered pain medication and manage pain for one Resident (R1) of three reviewed for pain in a sample of three. This failure resulted in R1's increased level of pain and decline in Activity of Daily Living.
Inspectors wroteBased on record review and interview the facility failed to follow their Abuse Prevention policy to perform a health care worker background check and failed to obtain a fingerprint based criminal history check of an employed unlicensed dietary aide with two disqualifying criminal offenses. These failures have the potential to affect all 89 residents residing within the facility.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication cart was locked at all times when not in view, and failed to ensure Schedule II meds were double locked in the Medication Cart when the cart was not in view, per facility policy. This failure has the potential to affect five residents (R11, R12, R13, R14, and R15) of five residents reviewed for Pharmaceutical Services.
Inspectors wroteBased on observation, record review and interview the facility failed to prevent a resident fall with injury for one of four residents (R3) reviewed for falls in a sample of four. This failure resulted in R3 sustaining a large hematoma to right forehead and R3 having pain. On 1/2/2023 at R3 was observed sitting in the main dining room in a reclining chair. R3 had a noticeable hematoma to right forehead with a yellowish color around the hematoma and down R3's right lateral face. R3's Nurses Notes, dated 12/202/2023, documents, (R3) was noted on the floor in her room. (R3's) face was down to right side of bed with head towards door and feet to window. (R3) was rolled over onto back and noted a large bump to right forehead. (R3) was sent to the local hospital for evaluation. [...]
Inspectors wroteBased on observation, record review, and interview the facility failed to ensure residents were showered twice weekly per their plan of care and their preferences for three of three residents (R1, R2, R3) reviewed for Activities of Daily Living in the sample of three residents. 1. R1's Baseline Care Plan documents R1 was admitted to the facility on [DATE], is dependent on two staff for bathing, and dependent on one staff for grooming. The facility's Shower Log and R1's Shower/Abnormal Skin Reports dated 11-10-23 (Admission) through 11-28-23 document R1 has only had two baths/showers since R1's admission on [DATE] and document R1 has had no bath or shower since 11-17-23. On 11-28-23 at 8:45 AM R1 was lying in bed. R1's face had a dried crusty substance around his mouth and R1's hair was unkempt. R1's beard and mustache were grown out approximately a half an inch long. [...]
Inspectors wroteBased on interview and record review, the facility failed to prevent a fall for one (R4) of three residents reviewed for accidents in a sample of three. This failure resulted in R4 being transferred to the Emergency Department/ED with injuries to face, sustaining a hematoma and an uncontrolled nose bleed.
Inspectors wroteBased on interview and record review the facility failed to follow physician orders for one resident (R64) of 19 residents reviewed for physician orders in the sample of 39. This failure resulted in R64 experiencing unresolved back and shoulder pain.
Inspectors wroteBased on interview and record review, the facility failed to provide the services of a registered nurse (RN) for eight hours in a 24-hour period, seven days a week. This failure has the potential to affect all 81 residents residing in the facility. Findings Include: Facility Facility Assessment Tool, revised 8/15/23 documents the average daily census is 70-80 residents. Staffing Plan: The facility's plan to ensure sufficient staff to meet the needs of the residents at any given time is based on the staffing calculator, which takes into consideration the facility census and acuity levels impacting staffing needs. Review expectations for minimum staffing requirements at the federal and state level. Federal law requires nursing homes to have sufficient staff to meet the needs of residents, to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. [...]
Inspectors wroteBased on record review and interview, the facility failed to employ a qualified Social Service Director. This has the potential to affect all 81 residents residing in the facility.
Inspectors wroteBased on interview and record review the Facility failed to ensure that the designated Medical Director, designated Director of Nursing and designated Infection Preventionist was present at the Facility's Quality Assurance Meetings. This failure has the potential to affect all 81 Resident's residing in the Facility.
Inspectors wroteBased on record review and interview the facility failed to thoroughly monitor active infections in the facility and failed to implement their Antibiotic Stewardship Program. These failures have the potential to affect all 81 residents who currently reside in the facility. Findings Include: The Facility's Antibiotic Stewardship Program dated 3/20/23 documents the purpose of the program is, To improve the use of Antibiotics in healthcare to protect residents and reduce the threat of antibiotic resistance through a set of commitments and actions designed to optimize the treatment of infections while reducing adverse events associated with antibiotic use. This will be accomplished utilizing the Core Elements. Tracking: Monitor at least one process measure of antibiotic use and at least one outcome from antibiotic use. [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to develop a Comprehensive Care Plan for Hospice services for two residents (R36 and R52); Care Plan for PTSD (Post Traumatic Stress Disorder) for one resident (R64) and Care Plan for smoking, weight loss, and risk for urinary tract infection for one resident (R131) of 20 residents reviewed for care planning in the sample of 39.
Inspectors wroteBased on interview and record review the facility failed to revise resident care plans for five (R8, R36, R52, R54, R64) of 20 residents reviewed for care planning in the sample of 39.
Inspectors wroteBased on record review and interview the facility failed to offer and/or administer Influenza and Pneumonia Vaccinations for four residents (R12, R44, R49 and R77) of five reviewed for immunizations in a total sample of 39. Findings Include: The Facility's Immunization of Residents dated 5/19/23 documents (This Facility) will offer immunizations and vaccinations that aid in the prevention of infectious diseases unless medically contraindicated or otherwise ordered by the resident's attending physician or the facility's medical director. Assess all newly admitted residents' pneumococcal and influenza vaccination status upon admission and record last known immunization on the resident's Immunization Record. Offer the Pneumococcal vaccination within 30 days of admission. Offer the influenza immunization annually from September 1st through March 31st. [...]
Inspectors wroteBased on observation, interview and record review the facility failed to monitor unwitnessed fall injuries and initiate fall interventions (R64) and assess for Smoking Safety and Smoking assistance (R131) for two of six residents reviewed for accidents in a sample of 39.
Inspectors wroteBased on observation, interview and record review the facility failed to perform hand hygiene and put on Personal Protective Equipment upon entering an Enhanced Barrier Precautions room of residents with suprapubic indwelling urinary catheters for two residents (R26 and R33) of six residents reviewed for indwelling urinary catheters in a sample of 39.
Inspectors wroteBased on observation, interview, and record review the facility failed to follow their Resident Weight Monitoring policy and procedure for two (R54 and R131) of seven residents reviewed for nutrition in the sample of 39.
Inspectors wroteBased on interview and record review the facility failed to assess a resident for Post Traumatic Stress disorder/PTSD for one of two residents (R50) reviewed for PTSD in a sample of 39. Findings Include: The Facility's Trauma Informed Care Policy dated 8/23/23 documents the purpose of the policy is to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Upon admission the Social Service Director will review hospital discharge records and interview the resident or the resident's representative to determine any history of trauma. [...]
Inspectors wroteBased on observation, interview and record review the facility failed to administer medications to one resident at a time for three residents (R17, R36, R61) of 19 residents reviewed for medications in the sample of 39. The Facility's Medication Administration Policy dated 11/18/17 documents, Drug administration shall be defined as an act in which a single dose of a prescribed drug or biological is given to a resident by an unauthorized person in accordance with all laws and regulations governing such acts. The complete act of administrations entails removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container) verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the time and dose given. [...]
Inspectors wroteBased on record review and interview the facility failed to address Medication Reconciliation Reports for two residents (R12 and R49) of five residents reviewed for medication review in a total sample of 39. Findings Include: The Facility's Consultant Reports policy dated 1/6/10 documents, It is the policy of (this facility) that any consultant reports with irregularities be reported to the resident's attending Physician and Director of Nursing and the report must be acted upon. The resident's attending Physician will review the consultant reports for acceptance or rejection and check the form accordingly. 1. R12's Consultation Report dated 6/8/23-6/9/223 documents, (R12) receives dual antiplatelet therapy with Aspirin Low Dose and Clopidogrel and does not have a CBC (Complete Blood Count) documented in the medical record within the previous 6 months. Recommendation: [...]
Inspectors wroteBased on record review and interview the facility failed to identify target behaviors for use of psychotropic medications for three residents (R12, R50 and R54) and failed to determine the origin of a psychosis diagnosis for one resident (R54) of five residents reviewed for mood and behavior in a total sample of 39. Findings Include: The Facility's Psychotropic Medication Policy documents It is the policy of this facility that residents shall not be given unnecessary drugs. Unnecessary drug is any drug used: 1. in an excessive dose, including in duplicative therapy 2. For excessive duration 3. Without adequate monitoring 4. Without adequate indications for its use 5. In the presence of adverse consequences that indicate the drugs should be reduced or discontinued. [...]
Inspectors wroteBased on interview and record review the facility failed to ensure resident's complete/accurate medical records and thinned records were easily assessable for two (R26, R54) of two residents reviewed for medical records in the sample of 39.
Inspectors wroteBased on observation, interview, and record review, the facility failed to post the required nurse staffing information. This has the potential to affect all 81 residents residing in the facility.
Inspectors wroteBased on observation, interview, and record review, the facility failed to evaluate each residents fall, failed to conduct root cause analysis and failed to implement interventions to reduce the risk of future falls for one of three residents (R38) reviewed for falls in the sample of 33. This failure resulted in R38 falling on 7/19/22 and receiving a trimalleolar fracture of the right ankle.
Inspectors wroteBased on observation, record review and interview the facility failed to perform a pressure ulcer wound treatment as ordered for one of two residents (R12) reviewed for pressure ulcers in a sample of 33. Findings Include: The facility policy titled Skin Condition Monitoring, dated 1/2018, documents It is the policy of this facility to provide proper monitoring, treatment, and documentation of any resident with skin abnormalities. On 10/4/2022 at 10:47 AM V7/LPN (Licensed Practical Nurse) performed wound care on (R12) coccyx area. Cleansed area with a wound cleanser, area was patted dry, and Alginate Calcium with Silver (topical wound dressing) with a secondary dressing of gauze island border was applied. Wound size measured approximately 1.5 cm x 0.5 cm (centimeters) with yellow - tannish dead tissue in the wound bed. Peri-wound is red. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to justify duplicative antipsychotic therapy of three antipsychotics, failed to obtain a physician ordered psychiatric evaluation and failed to document a clinically indicated diagnosis and adverse behaviors to warrant the use of an antipsychotic for two of three residents (R15, R27) reviewed for antipsychotic medications in the sample of 33.
| Date | Penalty | Amount or length |
|---|---|---|
| March 28, 2026 | Fine | $64,120 |
| December 12, 2024 | Fine | $16,965 |
| October 4, 2024 | Fine | $31,993 |
| July 25, 2024 | Fine | $52,679 |
| July 25, 2024 | Payment Denial | 25 days from August 29, 2024 |
| March 13, 2024 | Fine | $22,950 |
| March 13, 2024 | Payment Denial | 9 days from May 7, 2024 |
| November 17, 2023 | Fine | $62,654 |
| November 17, 2023 | Payment Denial | 32 days from December 15, 2023 |
| September 21, 2023 | Fine | $9,263 |
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) | 3.42 | 3.45 | 3.86 |
| Registered nurses | 0.20 | 0.72 | 0.69 |
| All nursing staff on weekends | 2.90 | 3.07 | 3.42 |
| Nurse aides | 2.23 | ||
| Licensed practical nurses | 0.99 | ||
| Nursing staff turnover (share who left in a year) | 65.9% | 44.5% | 45.8% |
| Registered nurse turnover | 93.3% | 41.8% | 42.9% |
| Administrators who left | 3 |
CMS expects 5.35 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 3.64 on weekdays and 2.90 on weekends, 20% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.2% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.03 in April to June 2025 to 3.42 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 | 3.42 | 0.20 | 3.64 | 2.90 | 0.2% | 3 of 90 | 89 |
| Oct to Dec 2025 | 3.64 | 0.23 | 3.81 | 3.18 | 0.1% | 2 of 92 | 83 |
| Jul to Sep 2025 | 3.47 | 0.23 | 3.70 | 2.89 | 1.9% | 0 of 92 | 84 |
| Apr to Jun 2025 | 4.03 | 0.29 | 4.24 | 3.53 | 12.6% | 0 of 91 | 87 |
| 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 | 26.6 | 13.4 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.7 | 0.9 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.2 | 1.5 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 5.1 | 3.1 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.0 | 2.2 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 36.9 | 14.3 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 4.1 | 4.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 12.7 | 21.7 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 25.4 | 26.1 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 15.6 | 13.8 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 4.7 | 2.0 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 3.7 | 2.2 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Timbercreek Rehab 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 (40.7% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
40.7% 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. 41 eligible stays.
10.8% 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. 49 eligible stays.
7.2% this home
No different from the national rate
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. 25 eligible stays.
12.5% this home
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. 24 residents counted.
0.0% this home
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. 38 residents counted.
2.1% this home
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. 38 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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