Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Prairie Crossing Lvg & Rehab during CMS and state inspections, most recent first.
Food items in the kitchen and storage areas were found unlabeled, including refrigerated items, dry goods, and items on serving carts. The low-temp dish machine was operating at 10 ppm chlorine instead of the required 50 ppm, yet dishes, flatware, and cookware were still processed and put away for use. Pureed food on the steam table was also held at 131 degrees F and then served, below the facility’s 135 degrees F holding standard.
Missed Pureed Bread at Noon Meal: A Dietary Manager changed the noon menu when the facility did not have the breading for the planned chicken entrée, but pureed bread and margarine were not served to 8 residents on a puree diet. Pureed foods were plated and sent out, while residents on a general diet received chicken breasts on a bun. The Dietary Manager later stated he forgot the pureed bread and normally would puree bread and place it on the tray.
Staff failed to follow infection control practices during catheter care, medication administration, and meal assistance. A resident with an indwelling urinary catheter and ESBL/UTI history was cared for without the required gown during EBP, an LPN administered meds without hand hygiene and picked up a dropped tablet with bare hands, and staff handled a resident’s food with bare hands while feeding her.
Missed Weights and BP Monitoring for Two Residents: The facility did not consistently obtain ordered daily weights for two residents with CHF and did not consistently obtain BP every shift for one resident after a fall. One resident’s record showed multiple missing weight and BP entries despite orders for daily weights and shift BP checks, and the resident said staff did not always check BP every shift. A second resident’s record showed numerous missed scheduled weights over several months, and the DON acknowledged missing entries and stated CNAs obtained the weights while nurses were responsible for ensuring they were completed and entered.
A resident with an indwelling catheter and hx of UTI/ESBL had catheter tubing changed without being wiped with alcohol before connection, and the leg bag was placed on used bed linens during the change. Another resident with an indwelling catheter had tubing observed touching the floor in the dining room on multiple occasions. The DON and Administrator stated tubing should be kept off the floor for infection control, and facility policy required the tubing junction to be wiped and the drainage bag/tubing kept off the floor.
Failure to maintain oxygen tubing and care planning for a resident using O2. The resident had an oxygen concentrator with tubing that was not changed weekly, and the humidification bubbler was undated. The resident had active orders for titrated O2 and PRN O2 for respiratory distress, with multiple documented uses of nasal cannula O2 and desaturations on room air. The care plan did not include oxygen use or equipment maintenance, and the RN/care plan coordinator stated the oxygen care plan had been missed.
A resident with a history of CHF, HTN, AFib, falls, and weakness had scheduled meds left in a cup at the bedside instead of being directly administered. The resident said staff always leave the pills there and he takes them when he feels like it, and he did not know what the meds were or why he took them. The RN said she left the meds because the resident was eating, even though there was no order, assessment, or care plan for self-administration, and the DON said meds should not be left at the bedside.
The facility failed to cool a pork roast before freezing and did not use serving utensils while serving food, affecting all residents. A pork roast was improperly stored without a cooling log, and a staff member used gloved hands instead of utensils to serve food, increasing cross-contamination risk.
A facility failed to obtain daily weights and notify the cardiologist for a resident with heart failure when weight gain exceeded set parameters. The resident experienced several significant weight increases without the cardiologist being informed, except on one occasion. The facility's records showed missing weight entries, and the Director of Nursing confirmed the lack of documentation for notifying the cardiologist, contrary to the facility's policy.
A resident dependent on staff for care was found in an unkempt state, with dirty hair and poor oral hygiene, indicating a failure to provide regular showers and mouth care. Despite the care plan requiring extensive assistance, documentation showed only one shower was completed in July. Staff interviews revealed showers are scheduled twice a week but not documented in the electronic record, and the facility lacked a specific policy for providing showers.
The facility failed to prevent resident-to-resident abuse, resulting in multiple incidents involving aggressive behavior by a resident with severe cognitive impairment. Despite documented incidents of aggression, the facility did not implement effective measures to separate the aggressive resident from others or closely monitor interactions, leading to physical altercations and injuries.
Unlabeled food, inadequate dish sanitizing, and improper hot food holding
Penalty
Summary
Food was not consistently labeled in the kitchen and storage areas. During observation, French toast sticks in the refrigerator were in a bag that was not sealed or labeled, three resealable storage bags with sliced yellow cheese and sliced ham wrapped in clear wrap had no labels, plastic containers on two drink serving carts with thickener and hot chocolate powder were not labeled, two plastic containers with lids containing cereal were not labeled, four plates with rice krispie treats wrapped in plastic on a dry storage shelf had no labels, and a 22-quart container of brown sugar, a 3-liter plastic container of hot cereal mix, and 22-quart plastic containers on the shelf did not have labels. The Dietary Manager stated food is supposed to be labeled and dated, and that cheese and lunchmeat should have the best used by date on a label. A daily task list for kitchen staff also stated everything in the fridge, freezer, and storage areas must be labeled and dated. The facility also failed to maintain proper dish sanitation and food holding temperatures. The low temperature dishwasher was observed running with a chlorine sanitizer level of 10 ppm, below the stated 50 ppm requirement, and repeated testing did not reach 50 ppm even after the Dietary Manager manually primed the machine. Despite this, silverware, bowls, and pans continued to be run through the dishwasher and were put away for use. In addition, pureed sweet potatoes on the steam table were checked at 131 degrees Fahrenheit and were later served for lunch, while the facility stated the holding temperature for food on the steam table is 135 degrees Fahrenheit. The dish machine monitoring sheet showed the sanitizer level had not been documented on the day of the observation, and the facility policies stated flatware, serving dishes, and cookware must be cleaned, rinsed, and sanitized after each use and hot foods must stay above 135 degrees Fahrenheit during holding and service.
Missed Pureed Bread at Noon Meal
Penalty
Summary
The facility failed to provide pureed bread and margarine for the noon meal for 8 of 8 residents reviewed who were dining in the sample. The Week 3 Tuesday menu listed tater crusted chicken, smoked paprika sweet potatoes, green beans, bread/margarine, and fruit crisp for the noon meal, but on 1/27/26 at 12:15 PM the Dietary Manager stated the facility did not have the breading to prepare the tater crusted chicken and the menu was changed to chicken breast on a bun. At 12:47 PM, pureed foods were being plated in the kitchen and placed on resident trays, but no pureed bread was included. The residents identified as R7, R33, R54, R4, R48, R37, R23, and R43 did not receive pureed bread and butter at the noon meal, while residents on a general diet received chicken breasts on a bun. Later that afternoon, the Dietary Manager stated he forgot the pureed bread and said he normally would take bread, puree it, and place it on the tray.
Infection Control Failures During Catheter Care, Medication Pass, and Meal Assistance
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions were followed for a resident with an indwelling urinary catheter and a history of ESBL/UTI infection. The resident had diagnoses including senile degeneration of the brain, traumatic brain injury, dementia, neuromuscular bladder, and a history of UTI, and the facility assessment showed severe cognitive impairment with staff assistance needed for personal hygiene, dressing, and toileting. The resident’s orders included an indwelling urinary catheter and EBP, and the care plan addressed the catheter and ESBL history. During observation, a CNA changed the resident’s catheter drainage bags, wore gloves but not a gown, and then transferred the resident from bed to wheelchair while leaning over the bed and touching it with her body and linens. The facility also failed to ensure hand hygiene was performed during a medication pass. A LPN was observed administering morning medications to four residents without sanitizing or washing hands before starting or between residents. While giving one resident’s medication, a tablet fell onto the medication cart; the LPN picked it up with bare hands, placed it in the medication cup, and administered it to the resident. The LPN then completed the medication pass and washed his hands only afterward. The LPN stated he did not use hand sanitizer and only washed his hands at the end of the pass. The facility further failed to ensure staff did not touch a resident’s food with bare hands during meal assistance. A resident with Alzheimer’s disease, hallucinations, anxiety disorder, anemia, type II diabetes mellitus, heart failure, chronic kidney disease stage 4, and hospice services had a regular diet and required assistance with eating. During lunch, staff picked up the resident’s bun with bare hands, spread mayonnaise on it, held it in place with a bare hand while cutting it, and then another CNA picked up the sandwich with bare hands and fed the resident multiple bites. The DON stated staff do not typically wear gloves when feeding residents, and the Administrator stated staff should be using utensils, not bare hands.
Missed Weights and Blood Pressure Monitoring
Penalty
Summary
The facility failed to consistently obtain daily weights for residents with congestive heart failure and failed to consistently obtain blood pressure readings every shift for a resident following a fall. For one resident with a history that included fluid overload, frontotemporal neurocognitive disorder, congestive heart failure, and falls, the care plan directed blood pressure monitoring every shift after a fall, and active orders required daily weights and blood pressure every shift. Review of the eMAR and weight/vitals logs showed multiple missing weight entries and missing blood pressure entries across October 2025 through January 2026. The resident stated that staff had been checking blood pressure 2 to 3 times a day since the fall, but also said they had missed a couple of days and did not always check blood pressure every shift. The DON stated that daily weights are important for a resident with CHF to monitor for changes to report to the physician and acknowledged a few missing entries. The DON also stated that nurses are expected to follow physician orders and that if resident information is not documented on the MAR, it could mean it was not done or was charted elsewhere, but no documentation for the missing weights or blood pressures was provided. For a second resident with diagnoses including heart failure, Parkinson’s disease, dementia, anxiety disorder, depression, restlessness, and agitation, the order summary showed weights ordered three times weekly for CHF. Review of the record showed many missed weights: only 4 weights were entered in November when 9 were expected, only 3 were entered in December when 14 were expected, and only 1 was entered in January when 12 were expected. The January MAR and TAR did not show any weight order, and the DON stated there were quite a few missing weights and that the CNAs obtain the weights while the nurse is responsible for ensuring they are completed as ordered. A RN stated that CNAs obtain the weights and give them to the nurses, who enter them into the computer.
Catheter Tubing Not Cleansed and Left on Floor
Penalty
Summary
The facility failed to ensure catheter tubing was cleansed prior to use for a resident with an indwelling urinary catheter and a history of UTI and ESBL infection. The resident had diagnoses including senile degeneration of brain, traumatic brain injury, dementia, neuromuscular bladder, and a history of UTI, and was assessed as having severe cognitive impairment and requiring staff assistance for personal hygiene, dressing, and toileting. During observation, a CNA was changing the resident’s overnight catheter bag to a daytime leg bag, and the leg drainage bag was lying directly on used bed linens. The CNA wore gloves to disconnect and connect the catheter tubing but did not sanitize the tubing before connecting the catheter tubes. The DON/IC Preventionist stated the tubing should be wiped with an alcohol swab before connecting because it is a relatively sterile field and the alcohol helps prevent UTIs. The facility policy required wiping the Foley catheter/drainage tubing junction with alcohol before disconnecting and wiping the connection tip of straight tubing with alcohol. The facility also failed to ensure catheter tubing remained off the floor for another resident with an indwelling urinary catheter. This resident had diagnoses including dementia, chronic kidney disease stage 2, a history of UTI, sepsis, urine retention, and obstructive and reflux uropathy, and was assessed as severely cognitively impaired, dependent on staff for toilet hygiene and lower body dressing, and frequently incontinent of bowel. On three separate observations, the resident was sitting in the dining room with catheter tubing touching the floor. The DON and Administrator stated the tubing should not touch the floor for infection control. The facility policy stated the drainage bag and tubing should be kept off the floor at all times to prevent contamination and damage.
Failure to Maintain Oxygen Tubing and Care Plan
Penalty
Summary
The facility failed to ensure oxygen tubing was changed weekly for one resident who used oxygen. On 1/27/26 at 11:16 AM, the resident had an oxygen concentrator in the room, and the tubing attached to the concentrator was dated 12/9/25. The humidification bubbler attached to the machine was not dated and was half full. The facility administrator stated on 1/28/26 at 2:14 PM that oxygen tubing is to be changed weekly for infection control purposes, and also stated the tubing is changed when the bubblers are running low because it is included in the setup. The resident’s physician orders in January 2026 directed oxygen to be titrated to maintain oxygen saturation at or above 90%, with oxygen also permitted for respiratory distress to maintain O2 saturation as tolerated. Progress notes from late December 2025 through late January 2026 documented multiple uses of oxygen via nasal cannula, and on 1/28/26 at 7:41 AM the physician was contacted because the resident continued to need PRN oxygen with desaturations at 87-88% on room air. The resident’s care plan dated 1/9/26 did not include a plan for oxygen use or maintenance of equipment/nasal cannula changes, and the RN/care plan coordinator stated she missed putting an oxygen care plan in place. The resident’s diagnoses included Alzheimer’s disease, dementia, unsteadiness on feet, atherosclerosis, hypertension, delirium, hyperlipidemia, restlessness and agitation, and personal history of COVID-19.
Medications Left at Bedside Without Self-Administration Order
Penalty
Summary
The facility failed to ensure that prescribed medications were safely administered to a resident as ordered by the physician. R42’s face sheet documented an admission date of 02/04/2025 and a medical history that included lack of coordination, history of falling, muscle weakness, need for assistance with personal care, hypertension, atrial fibrillation, and congestive heart failure. On 01/29/2026 at 09:09 AM, surveyors observed a small clear plastic cup with R42’s name on it containing four tablets on the resident’s bedside table. R42 was asleep when the room was entered, then stated that staff always leave his pills there and that he takes them when he feels like it. He also said he did not know what the medications were or why he takes them. Review of the active physician orders showed empagliflozin 10 mg daily, furosemide 40 mg daily, lisinopril 2.5 mg daily, and metoprolol tartrate 12.5 mg daily, all scheduled for 08:00 AM. The eMAR documented these medications as administered by V11, RN. When interviewed, V11 said she brought the medications earlier but left them on the bedside table because R42 was eating, and she acknowledged that R42 did not have an order to self-administer medications and that she should not have left them at the bedside. The medical record contained no active physician order, assessment, or care plan for self-administration. The DON stated she was not aware of any resident assessed to self-administer medications and said medications should not be left at the bedside.
Improper Food Handling and Lack of Cooling Logs
Penalty
Summary
The facility failed to properly cool a pork roast before freezing and did not use serving utensils while serving food, which affected all residents in the facility. During an observation, a pork roast was found in the refrigerator wrapped in aluminum foil with a date indicating it had been thawed for use in a meal. The Dietary Manager admitted that the roast was cooked previously and placed in the freezer without a cooling log, which is against the facility's policy to prevent foodborne illnesses. Additionally, it was revealed that temperatures of leftover food are checked but not logged, indicating a lack of proper documentation and adherence to food safety protocols. Furthermore, during a meal service observation, a staff member was seen using gloved hands to place garlic bread on residents' plates and using a spatula along with her hands to serve lasagna. The same gloves were used to access storage areas and drawers without being changed, which is contrary to the facility's policy that requires the use of clean barriers and changing gloves after touching contaminated surfaces. This practice increases the risk of cross-contamination, as confirmed by the Dietary Manager, who stated that staff are expected to use utensils to prevent such occurrences.
Failure to Monitor and Report Weight Changes in Heart Failure Resident
Penalty
Summary
The facility failed to ensure daily weights were obtained for a resident diagnosed with heart failure and did not notify the resident's doctor when weight gain exceeded the set parameters. The resident, who had severe cognitive impairment and required assistance for daily activities, had an active order for daily weight monitoring and to inform the cardiologist if there was a weight gain of more than 2-3 pounds overnight or 5 pounds in a week. Despite this, the resident experienced several instances of significant weight gain, such as a 3.3-pound increase on July 1, a 5.9-pound increase on July 6, and a 6.9-pound increase on July 25, without the cardiologist being notified except on September 30. The facility's records showed multiple days where the resident's weight was not recorded, and the Director of Nursing confirmed the lack of documentation regarding notification to the cardiologist. The facility's policy required notifying the physician of changes in the resident's condition, which was not adhered to in this case. The Director of Nursing acknowledged the oversight and the importance of notifying the cardiologist to monitor for potential exacerbations of congestive heart failure.
Failure to Provide Adequate Personal Hygiene Care
Penalty
Summary
The facility failed to ensure that a dependent resident, identified as R1, received adequate assistance with activities of daily living, specifically in providing regular showers. R1, who was admitted with multiple diagnoses including sepsis, pneumonia, urinary tract infection, and pressure ulcer, was observed to be dependent on staff for all care due to limited mobility and weakness from a cardiovascular accident. Despite the care plan indicating the need for extensive assistance with bathing and showering, R1 was found in an unkempt state with dirty hair and a thick layer of residue on her teeth, suggesting inadequate personal hygiene care. Interviews with facility staff revealed that showers for residents are scheduled twice a week and documented on shower sheets, not in the electronic record. However, a review of R1's shower sheets for July showed only one completed shower and one refusal, with no evidence of additional showers being offered or documented. The Director of Nursing stated that residents should receive at least one shower each week and that refusals should be reported to the nurse. Additionally, the facility lacked a specific policy regarding the provision of showers, although there was a policy for mouth care, which was also not adequately followed for R1.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to have interventions in place to prevent resident-to-resident abuse, resulting in multiple incidents involving three residents. Resident R2, who had severe cognitive impairment and behavioral disturbances, exhibited aggressive behaviors towards other residents and staff. Despite multiple documented incidents of aggression, including physical and verbal threats, the facility did not implement effective measures to separate R2 from other residents or closely monitor his interactions, particularly with Resident R3, who also had cognitive impairments but no documented behavioral symptoms. On several occasions, R2's aggressive behavior led to physical altercations with R3. For instance, R2 pushed R3 from behind, causing him to stumble and attempt to retaliate by moving a wheelchair towards R2. In another incident, R2 pushed R3, who then fell into Resident R1, resulting in R1 sustaining a hematoma and experiencing significant pain. Despite these incidents, the facility's care plans for R2 and R3 did not include specific interventions to keep them separated or ensure close monitoring when they were around each other. Staff interviews revealed a lack of communication and awareness regarding the incidents and the necessary interventions. Some staff members were unaware of the previous altercations between R2 and R3, and there was no consistent approach to managing R2's aggressive behavior. The facility's abuse prevention policy emphasized the need for immediate evaluation and appropriate interventions to ensure resident safety, but these measures were not effectively implemented, leading to repeated incidents of resident-to-resident abuse and injury.
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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 Shabbona
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aperion Care Dekalb | 12 mi | ★★★★★ | 6 | 0 |
| Dekalb County Rehab & Nursing | 14 mi | ★★★★★ | 1 | 0 |
| La Bella Of Rochelle | 14.5 mi | ★★★★★ | 12 | 0 |
| Rochelle Rehab & Health Care Center | 14.7 mi | — | 0 | 0 |
| Pavilion On Main Street, The | 15.5 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.