15 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
9 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Freeport, IL
3-star overall rating with 3-star inspections with 15 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
2946 South Walnut Road, Freeport, IL
(815) 235-6173
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
148
Certified beds
Average residents
48
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-11-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.88
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.57
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.88
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
4.34
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.45
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.85
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.01
CMS adjusted RN staffing hours
Adjusted total hours
4.97
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Program rank
4,621
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.23
Composite VBP score used to determine payment impact.
Payment multiplier
0.9922
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
5.94
Performance 39.39% · Measure score 5.94 · Achievement 5.94 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.90
Baseline 3.76 hours · Performance 3.62 hours · Measure score 1.90 · Achievement 1.90 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.38% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 33 · Observed rate 9.09% · Lower 95% interval 6.34% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 15 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 17.65% |
8.2%
9.4 pts better
|
Numerator 12 · Denominator 68 |
| Staff flu vaccination coverage | 39.19% |
42%
2.8 pts worse
|
Numerator 29 · Denominator 74 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.6%
10.4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
91.6%
8.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.2% |
3.3%
2.1 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.5% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.3% |
50.3%
46 pts better
|
11.4%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 6.9% · Q3 6.7% · Q4 0.0% · 4Q avg 4.3% |
| Percentage of long-stay residents who lose too much weight | 2.2% |
6.5%
4.3 pts better
|
5.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.8% · Q3 0.0% · Q4 3.0% · 4Q avg 2.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.9% |
18.5%
1.4 pts worse
|
19.6%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 19.4% · Q3 22.2% · Q4 20.6% · 4Q avg 19.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 41.4% |
22.8%
18.6 pts worse
|
16.7%
24.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.3% · Q2 45.2% · Q3 37.0% · Q4 39.3% · 4Q avg 41.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.3% |
17.2%
4.1 pts worse
|
16.3%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.4% |
15.0%
0.6 pts better
|
14.9%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 15.6% · Q3 6.5% · Q4 19.4% · 4Q avg 14.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
1.1%
0.6 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.1% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.3% |
1.7%
4.6 pts worse
|
1.7%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 2.5% · Q3 7.3% · Q4 7.5% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.6% |
21.3%
9.7 pts better
|
19.8%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 14.7% · Q3 8.7% · Q4 17.0% · 4Q avg 11.6% |
| Percentage of long-stay residents with pressure ulcers | 10.8% |
5.2%
5.6 pts worse
|
5.1%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 19.5% · Q3 5.4% · Q4 6.8% · 4Q avg 10.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.0% |
68.8%
24.2 pts better
|
81.7%
11.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.3% · Q2 90.7% · Q3 93.0% · Q4 95.1% · 4Q avg 93.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.3% |
2.3%
1 pts worse
|
1.6%
1.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 4.5% · Q3 0.0% · Q4 0.0% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.7% |
63.0%
23.7 pts better
|
79.7%
7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.7% |
Survey summary
Top issue: Quality of Life and Care (6 deficiencies)
9 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
14 fire-safety deficiencies
Top issue: Emergency Preparedness (8 deficiencies)
Top issue: Pharmacy Service (3 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-02-14
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-02-14
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-02-14
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-02-14
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-02-14
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-02-28
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-02-14
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-02-14
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-06
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-02-23
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2024-02-23
Fire Safety
Provide primary/alternate means for communication.
Corrected 2024-02-23
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-02-23
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-02-23
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-02-23
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-02-23
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-02-23
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-23
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2024-02-23
Fire Safety
Install proper backup exit lighting.
Corrected 2024-02-23
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-23
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-02-23
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-02-23
Fire Safety
Provide primary/alternate means for communication.
Corrected 2023-02-14
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-03-05
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-03-05
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-19
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2023-01-19
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-06
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-02-03
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-24
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-02-02
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-01-12
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-02-03
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-02-01
Inspection history
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-06-20
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-02
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-11
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-02-28
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-07
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-02-28
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-03-07
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-02-28
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-02-28
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-02-28
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-02-28
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-28
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-28
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-02-28
Health
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.
Corrected 2025-02-07
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-07-19
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-19
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-05-13
Health
Respond appropriately to all alleged violations.
Corrected 2024-05-13
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-02-10
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-10
Health
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.
Corrected 2024-02-10
Health
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.
Corrected 2024-02-10
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-02-10
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-07
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-02-10
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-01-21
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-01-21
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-21
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-21
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-12-19
Health
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.
Corrected 2022-12-31
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-12-31
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-12-31
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-12-31
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-31
Penalties and ownership
Payment Denial · denial start 2025-02-26 · 114 days
114 day denial
5% Or Greater Direct Ownership Interest · Organization
W-2 Managing Employee · Individual
Nearby options
Freeport, IL
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1-star overall rating with 1-star inspections with $150,091 in total fines with 23 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
Freeport, IL
2-star overall rating with 2-star inspections with $88,479 in total fines with 14 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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