Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at East Bank Center, Llc during CMS and state inspections, most recent first.
A resident with multiple comorbidities, including mobility impairment, reported that the hot water knob on her bathroom sink had been broken since her admission and that CNAs knew about the issue. During observation, the surveyor found the hot water knob loose, and it fell off when turned; later, the Maintenance Director confirmed the knob had been previously glued and could still be lifted off, acknowledging it should not come off and might require sink replacement. The Administrator stated she was unaware of the broken sink but agreed the knob should be intact and functional. This condition was inconsistent with the facility’s Preventative Maintenance & Inspections Policy, which requires systematic inspection, timely detection, and prompt repair or replacement of equipment to maintain it in satisfactory operating condition.
Surveyors found that food items in the kitchen were not properly labeled or dated, and a sanitizer solution used for cleaning was below the required concentration. Opened and undated food items were observed in both the refrigerator and freezer, and the sanitizer solution was confirmed to be below policy standards. These failures had the potential to impact all residents in the facility.
Two residents were unable to operate their televisions due to missing or nonfunctional remotes, despite expressing their preferences and notifying staff. One resident was unable to turn off or control her TV, affecting her sleep, while another could not locate her remote and was unable to watch TV for leisure. The facility lacked a policy addressing resident choices related to such preferences.
An LPN failed to follow proper infection control procedures during wound care for a resident with multiple health conditions, including not consistently changing gloves between wound cleaning and ointment application and initially using a gloved finger instead of a sterile applicator. The DON confirmed these lapses, and the facility lacked a specific policy for wound care infection control.
Due to a broken dumbwaiter, the facility served primarily cold foods for an extended period, offering limited hot meal options. Several residents reported dissatisfaction with the repetitive cold food choices and stated their preferences for hot meals were not honored. Some residents relied on family members to bring in food, and a formal complaint was filed regarding the lack of meal variety and accommodation of preferences.
A resident with swallowing difficulties and a prescribed pureed diet was served breakfast items, including eggs and oatmeal, that contained clumps and required chewing. Dietary staff acknowledged the improper consistency and deviation from the facility's policy, and the dietician confirmed that pureed foods should be smooth and not require chewing.
The facility did not have a full-time Activity Director, and there was no activity calendar or posted schedule for residents, contrary to facility policy. This affected all 32 residents, as confirmed by the Administrator and DON.
Five residents were found without access to individualized activity programs, with reports of boredom and lack of engagement beyond therapy. Staff confirmed the absence of an Activity Director and activity calendar, and care plans lacked specific, personalized activities, contrary to facility policy.
Two residents did not receive their evening medications on time due to an LPN being under the influence while on duty. The LPN argued with the residents, insisting the medications were given, but later tested positive for multiple substances. The Director of Nursing and Administrator intervened, and the residents eventually received their medications without negative outcomes.
The facility failed to repair the walk-in freezer, affecting all 24 residents. Thick frost and pooling water were observed on food packages, with a large puddle on the floor. The Dietary Manager noted the freezer was down, awaiting parts. The repair company stated they needed approval to order parts, and the Administrator was aware of the issue since July.
A resident with a stage 3 pressure injury was admitted to the facility without timely treatment orders, resulting in a five-day delay in care. Despite the presence of multiple open areas noted in the initial assessment, no treatment orders were obtained until 8/26/24. The wound nurse, DON, and wound care physician confirmed the delay, which was contrary to the facility's policy requiring prompt physician-ordered treatments.
Two residents experienced significant weight loss due to the facility's failure to provide prescribed dietary supplements. One resident, admitted with malnutrition, did not receive a Magic Cup supplement during a meal service, despite orders. Another resident, who was to receive Mighty Shakes twice daily, was not given the supplement during an observed lunch. The dietician confirmed the expectation for supplements to be administered as ordered, aligning with the facility's policy.
Two residents experienced delays in receiving medications due to failures in the order entry process at the facility. One resident with polyneuropathy waited 43 hours for pregabalin due to a prescription not being sent to the pharmacy, while another resident with oral thrush did not receive Miracle mouthwash because the order was not entered correctly. The facility's staff, including the DON, were unaware of the need to fax orders if not entered as pharmacy orders, leading to these deficiencies.
A facility failed to ensure a PRN psychotropic medication had a stop date not greater than 14 days for a resident. The resident had an active order for Ativan 0.5 MG every 12 hours as needed for anxiety, prescribed without a stop date. The DON confirmed that PRN orders for psychotropic medications should have a 14-day stop date, as per the facility's policy.
A resident with an indwelling urinary catheter was on enhanced barrier precautions, requiring staff to wear gloves and gowns during high-contact activities. However, staff members were observed assisting the resident without the necessary PPE, despite clear signage and facility policy outlining these requirements.
Failure to Maintain Resident Bathroom Sink in Safe, Functional Condition
Penalty
Summary
The facility failed to maintain a resident’s bathroom sink in a safe, functional condition. During observation, the surveyor noted that the hot water knob on the resident’s sink appeared loose, and when the surveyor attempted to turn on the hot water, the knob fell off onto the floor. The resident, who was sitting up in her wheelchair and cognitively intact, stated that the sink had been broken since her admission and that she could only get warm water if she “messed with it.” She reported that it was annoying, believed it should have been fixed by then, and indicated that her previous roommate had also said it was broken before, though she did not know for how long. The resident stated she did not recall maintenance coming in to fix it and that CNAs were aware the sink was broken. The resident’s diagnoses included disorder of the muscles, difficulty walking, reduced mobility, osteoporosis, an open abdominal wall wound, thrombocytopenia, PVD, hypothyroidism, and hypertension. Later observation with the Maintenance Director showed that the entire hot water knob moved when he attempted to turn on the water, and the surveyor was able to lift the knob completely off the hot water side. The Maintenance Director acknowledged that he had previously glued the knob and that it should not come off, stating he would need to replace it and that he believed a whole new sink might be required, for which he needed approvals. The Administrator stated that the knob on a resident’s sink should be intact so it functions properly, reported she did not know the sink was broken, and acknowledged that the sink should be in proper working order. The facility’s Preventative Maintenance & Inspections Policy required a preventative maintenance program to keep equipment in good repair through systematic inspection, detection, and correction of failures, and stated that replacement or repair of furnishings and equipment should be completed as soon as possible.
Improper Food Storage and Inadequate Sanitizer Levels Identified
Penalty
Summary
Surveyors observed that the facility failed to properly store and label food items and did not maintain sanitizing solution at the recommended level. During a kitchen tour, a red sanitation bucket near the three-compartment sink was tested and found to have a sanitizer concentration of 150 ppm, below the required 200 ppm. The Food Service Director confirmed that staff had been using this under-concentrated solution throughout the morning. Additionally, in the storage refrigerator, an opened and undated jar of marble glaze and a container of minced garlic were found, both visibly used. In the storage freezer, an undated and improperly closed bag of fish filets with visible ice crystals was observed. Staff confirmed that food items should be labeled with open and discard dates. The facility's policies require that food be labeled with the date received, the date opened, and the date by which it should be discarded to decrease the risk of foodborne illness. The policy for sanitation buckets specifies that the sanitizer should be mixed to a concentration of 200-400 ppm, as per manufacturer's directions. The Infection Preventionist confirmed that the sanitizer solution should be at the recommended level to effectively kill bacteria. These failures in food storage and sanitization practices had the potential to affect all 29 residents in the facility.
Failure to Support Resident Choice in TV Operation
Penalty
Summary
The facility failed to ensure that two residents were able to operate their televisions, thereby not supporting resident choice and self-determination. One resident, who was admitted for short-term rehabilitation following joint replacement surgery and had multiple comorbidities, reported that her television would not turn on with the remote. After staff manually turned on the TV, it remained on continuously, and the resident was unable to turn it off, change channels, or adjust the volume. Despite informing staff, the issue persisted, resulting in the resident being unable to sleep due to the TV staying on. Observation confirmed that neither of the two remotes in her room worked, and the TV remained on. The Maintenance Director stated the remote needed programming and that staff should have notified him. The DON acknowledged receiving a complaint about the issue and recognized the importance of sleep for the resident. Another resident reported that her TV remote had been missing since the previous day, and although she informed staff, the remote was not located. The resident stated she enjoyed watching TV to avoid boredom and keep her mind occupied. The Maintenance Director later identified that the extra remote in the first resident's room belonged to this second resident. Both residents' care plans indicated that watching TV was a preferred leisure activity. The facility's policy on resident rights did not address resident choices, and there was no separate policy regarding resident choices.
Infection Control Lapse During Wound Care
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to maintain proper infection control practices during wound care for a resident with multiple medical conditions, including a right pubic fracture, muscle weakness, and an open wound on the right elbow. The LPN donned gloves, prepared wound care supplies, and entered the resident's room. After cleaning the resident's right elbow with saline and applying antibiotic ointment with her gloved finger, the LPN removed her gloves and left the room to obtain additional supplies. Upon returning, the LPN placed a cotton-tipped applicator on the bedside table instead of the disposable tray, cleaned the resident's right knee, and again changed gloves before using the applicator to apply ointment to the knee. The LPN did not consistently change gloves between wound cleaning and ointment application and initially used her finger instead of a sterile applicator to apply ointment. The Director of Nursing (DON) observed the procedure and later confirmed that the LPN did not follow expected infection control protocols, specifically regarding glove changes and the use of sterile applicators. The facility's infection control policies provided to surveyors did not include a specific policy for general wound care or infection control practices for wounds without dressings. The observed lapses in infection control during wound care for this resident constituted a failure to prevent potential cross-contamination as required by facility policy and standard infection prevention practices.
Failure to Accommodate Resident Food Preferences During Emergency Cold Food Service
Penalty
Summary
The facility failed to accommodate residents' food preferences and choices for four out of six residents reviewed. From 6/11/25 to 6/24/25, the facility served primarily cold or room-temperature foods, such as cold cereal, canned fruit, deli meat sandwiches, potato chips, salads, ice cream, and pudding, with only a limited selection of hot foods like scrambled eggs, oatmeal, hamburgers, mashed potatoes, and grilled cheese sandwiches. This change was due to a broken dumbwaiter, which prevented safe transport of hot meals to the dining room. The facility implemented an emergency cold food plan, approved by the registered dietician, to avoid requiring kitchen staff to carry hot dishes up the stairs. The daily menus and staff interviews confirmed that the majority of meals during this period were cold foods, with only occasional hot options. Multiple residents expressed dissatisfaction with the repetitive and limited cold food options, stating that their preferences for hot meals were not met. Residents reported eating mostly sandwiches, salads, and fruit, and some relied on family members to bring in food from outside the facility. One resident described receiving a meal of watermelon, cottage cheese, and pudding, which she could not eat, while another stated he was tired of sandwiches and preferred hot meals. A complaint was filed by a resident and his family regarding the food service during this period. The facility's own policy states that clients' rights to be served food they choose and prefer will be honored, but this was not upheld during the emergency cold food plan.
Failure to Provide Proper Pureed Diet Consistency
Penalty
Summary
A deficiency occurred when the facility failed to provide a breakfast meal in a smooth pureed consistency as required for a resident with a downgraded diet due to swallowing difficulties. The resident, who had diagnoses of dementia and an unspecified muscle disorder, was assessed as needing a pureed diet for safety and nutritional intake. During observation, the resident was served scrambled eggs and oatmeal that contained clumps, requiring the resident to chew the food. The resident confirmed needing to chew the eggs, and staff acknowledged the presence of clumps in both the eggs and oatmeal. The dietary staff member responsible for preparing and serving the meal admitted to blending the eggs but noted they became clumpy on the steam table and should not have been served in that condition. The staff also stated that oatmeal was not pureed because the resident would not eat it if it was. The registered dietician confirmed that pureed foods should be silky smooth with no clumps and that residents should not have to chew pureed foods. The facility's policy requires pureed foods to have a semi-liquid to semi-solid, pudding-like consistency, with adjustments made as needed to achieve the correct texture.
Lack of Full-Time Activity Director and Activity Program
Penalty
Summary
The facility failed to employ a full-time Activity Director, as confirmed by both the Administrator and the Director of Nursing, who stated that there was no Activity Director on staff. Additionally, there was no activity calendar available for the month of March, and scheduled activities were not posted as required by the facility's own policy. This deficiency affected all 32 residents in the facility, as the absence of a qualified professional to direct the activities program and the lack of scheduled activities did not meet the facility's policy for supporting residents' physical, mental, and psychosocial wellbeing.
Failure to Provide Individualized Activity Program for Residents
Penalty
Summary
The facility failed to provide an activity program that met the individual interests and needs of five residents reviewed for activities. Observations revealed that these residents were either lying in bed or sitting in their rooms without access to activity calendars, and several reported that there were no activities available aside from therapy. Residents expressed boredom and dissatisfaction, noting the absence of activities, especially on weekends, and a lack of engagement during their stay. One resident in isolation reported not receiving any activities during their current admission, and others mentioned that activities such as BINGO were infrequent. Interviews with facility staff confirmed that there was no Activity Director and no activity calendar available for the month. Review of the residents' care plans showed identical, non-individualized activity goals and interventions, with no specific activities tailored to each resident's preferences. The facility's own policy requires activity programs to be individualized, scheduled seven days a week, and accessible to all residents, but these requirements were not met for the residents reviewed.
Failure to Administer Medications Timely Due to Impaired Staff
Penalty
Summary
The facility failed to ensure that two residents received their evening medications in a timely manner. On January 4th, two residents requested their evening medications from an LPN multiple times, but the LPN argued with them, insisting that the medications had been administered. The Medication Administration Records for both residents were signed as if the medications had been given by the Director of Nursing, although this was not the case. Later, the Director of Nursing received a concerning text message from the LPN, which led to further investigation. Upon investigation, it was discovered that the LPN was under the influence while on duty, exhibiting slurred speech and stumbling. A drug test revealed positive results for amphetamines, benzodiazepines, cocaine, and methamphetamine. The LPN admitted to using cocaine over the holidays but denied using drugs on the day in question. The Director of Nursing and the Administrator intervened, ensuring the LPN had no further contact with residents and eventually sent the LPN home. The residents were later given their missed medications, and a Nurse Practitioner confirmed that the delay did not result in any negative outcomes or side effects for the residents.
Failure to Repair Walk-In Freezer
Penalty
Summary
The facility failed to ensure the walk-in freezer was repaired and in safe working condition, potentially affecting all 24 residents. During a kitchen tour, thick frost was observed on food packages in the walk-in freezer, with frozen water pooling on boxes of cookies and diced turkey. A large puddle of water was also noted on the floor between the walk-in freezer and cooler, originating from the connecting door. The Dietary Manager acknowledged the freezer was down and mentioned a repair company had visited about a month ago, but they were waiting on a part to fix it. The freezer repair company representative stated they provided an estimate to fix the freezer on 7/30/24 and clarified that they were not waiting for parts but needed the facility to approve the estimate before ordering them. The Administrator confirmed awareness of the freezer issue since July when the repair company visited. The repair company's estimate indicated the walk-in freezer was not maintaining temperature, with the condenser short cycling due to a compromised pressure transducer, and issues with the thermostat and door closer.
Delay in Treatment Orders for Pressure Injury
Penalty
Summary
The facility failed to obtain timely treatment orders for a resident with a stage 3 pressure injury, leading to a delay in care. The resident was admitted with diagnoses including septic shock and a stage 3 pressure injury to her left heel and sacrum. Despite the severity of her condition, there were no active treatment orders for her pressure injuries until five days after her admission. The initial nursing admission assessment noted the presence of multiple open areas, but the Physician Order Summary and Treatment Administration Record showed no treatment orders until 8/26/24. The delay in obtaining treatment orders was confirmed by the wound nurse and the Director of Nursing, who acknowledged that no orders were obtained until 8/26/24. The wound care physician also confirmed that he was not contacted for treatment orders until five days after the resident's admission, which he deemed unacceptable. The podiatrist who treated the resident in the hospital also noted that treatment orders should have been in place sooner, as the dressing needed regular changes. The facility's policy on pressure ulcers indicates that the physician should order pertinent treatments, which was not adhered to in this case.
Failure to Provide Dietary Supplements Leads to Weight Loss
Penalty
Summary
The facility failed to ensure dietary supplements were provided to two residents, leading to significant weight loss. Resident 28 was admitted with diagnoses of protein-calorie malnutrition and muscle weakness. Despite a care plan indicating the need for dietary supplements, Resident 28 experienced a significant weight loss of 7.99% over ten days. Although a dietary supplement, Magic Cup, was ordered to be given with lunch, it was not provided during the observed meal service. The dietician, V4, confirmed the resident's poor nutritional status and expressed concern over the failure to provide the supplement. Similarly, Resident 5 experienced a significant weight loss of 8.9% over fifteen days. The resident was supposed to receive Mighty Shakes twice daily for weight support, as per the nutrition note and physician orders. However, during an observed lunch, the resident did not receive the prescribed supplement. The dietician, V4, acknowledged the expectation that supplements should be given as ordered. The facility's supplement policy from 2021 mandates that nutritional supplements be administered as prescribed, which was not adhered to in these cases.
Medication Delays Due to Order Entry Failures
Penalty
Summary
The facility failed to ensure timely pharmaceutical services for two residents, resulting in delays in medication administration. Resident R235, diagnosed with polyneuropathy, experienced a significant delay in receiving pregabalin, a medication prescribed to manage nerve pain. Despite the order being placed by a nurse practitioner, the prescription was not sent to the pharmacy promptly, leading to a delay of approximately 43 hours before the resident received the first dose. The delay was compounded by a documentation error on the Medication Administration Record (MAR), which incorrectly indicated that the medication had been administered when it had not. Similarly, Resident R11, who was experiencing oral thrush, did not receive the prescribed Miracle mouthwash due to a failure in the facility's order entry process. Although the nurse practitioner ordered the medication, it was not correctly entered into the system as a pharmacy order, nor was it faxed to the pharmacy. This oversight resulted in the resident not receiving the medication for several days, despite having a documented need for it. The Director of Nursing and other staff members were unaware of the requirement to fax orders to the pharmacy if not entered correctly, which contributed to the delay in medication delivery. The facility's policies indicated that medications should be received in a timely manner, but these procedures were not followed, leading to the deficiencies noted in the report.
Failure to Implement 14-Day Stop Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a PRN (as needed) psychotropic medication had a stop date not greater than 14 days for one resident reviewed for psychotropic medications. The resident, identified as R11, had an active order for Ativan 0.5 MG every 12 hours as needed for anxiety, prescribed by a Nurse Practitioner on September 5, 2024, without a stop date. During an interview on September 10, 2024, the Director of Nursing acknowledged that PRN orders for psychotropic medications, including Ativan, should have a stop date of 14 days. The facility's Time Limited Orders policy, effective October 25, 2024, also indicates that PRN Anxiolytics like Ativan should have a stop date of 14 days.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff adhered to the required personal protective equipment (PPE) protocols for a resident on enhanced barrier precautions. The resident, identified as R15, had an indwelling urinary catheter and was placed on enhanced barrier precautions, which required staff to wear gloves and gowns during high-contact activities such as transferring and handling the catheter. Despite clear signage outside R15's room indicating these precautions, staff members were observed not following the protocol. On two separate occasions, staff members were seen assisting R15 without wearing the necessary PPE. A Physical Therapist Assistant (V14) moved R15's urinary catheter drainage bag without gloves or a gown and assisted the resident to stand and walk. Similarly, a Certified Nursing Assistant (V15) also assisted R15 with standing and walking, again without wearing gloves or a gown. The facility's policy on enhanced barrier precautions, reviewed in April 2024, clearly stated the requirement for gown and glove use during high-contact activities for residents with indwelling medical devices.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Loves Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rock River Health Care | 0.2 mi | ★★★★★ | 14 | 1 |
| River Bluff Nursing Home | 0.6 mi | ★★★★★ | 6 | 0 |
| Willows Health Center | 1.3 mi | ★★★★★ | 13 | 0 |
| Alpine Fireside Health Center | 2 mi | ★★★★★ | 12 | 0 |
| Mercyhealth Javon Bea Hospital -snf | 2 mi | ★★★★★ | 0 | 0 |
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