New Summit Rehabilitation and Healthcare
1200 N Arlington Heights Rd, Arlington Heights, IL 60004 · For profit - Limited Liability company · 120 certified beds · (847) 392-9000 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- a high payroll-based staffing rating (4/5)
- it has 1 actual-harm citation
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- about 17% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 19.7% | 13.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.9% | 6.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 5.8% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 14.1% | 54.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.0% | 3.1% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 11.1% | 14.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 17.7% | 18.3% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 92.6% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 14.8% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 30.3% | 20.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 13.5% | 21.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.3% | 2.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 81.4% | 63.1% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 24.7% | 26.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 8.0% | 13.9% | 12.0% | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
62.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 499 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 53.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 328 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.06 therapist hours per resident per day in 2026Q1 — more than 2% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 62.2%CMS range 57.0–65.9 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.1%CMS range 9.9–14.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 53.4% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 45.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 50.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 97.8% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 99.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.2% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.2%CMS range 5.3–9.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.05 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 120 beds and averages 95.7 residents a day — about 80% occupied, or roughly 24 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.23 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.45 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.06 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.94 hrs/resident/day on weekends vs 4.35 on weekdays — 9% thinner on weekends. RN hours go from 1.57 to 1.15 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 43% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
22 citations, most serious first. The 11 most serious are shown; the remaining 11 are one tap away and print in full.
- Actual harm · Gcited before2025-06-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to have fall interventions in place for a resident at risk for fall and failed to ensure a resident was transferred safely for 2 of 20 residents (R33 and R36) reviewed for safety and supervision in the sample of 20. This failure resulted in R36 falling and sustaining a right ankle fracture that required surgical repair. The finding include: 1. R36's Face Sheet shows that she admitted to the facility on [DATE] with diagnoses of: cellulitis of right and left lower limbs, unsteadiness of feet, abnormalities of gait, reduced mobility and morbid obesity. R36's Functional Status Note dated 4/29/25 shows that R36 requires partial/moderate assistance to stand from sitting and transfer from bed to chair. On 6/9/25 at 11:35 AM, R36 was lying in bed. R36 had a cast on her right lower leg. R36 said that she fell in the bathroom and broke her leg. On 6/10/25 at 10:20 AM, V34 (R36's Spouse) said that he came in on 5/11/25 and R36 was sitting on the bathroom…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-06-11 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a cervical neck collar and ace wraps were in place as ordered, failed to clarify physician prescribed medication orders to ensure a resident received the medications and failed to perform an assessment immediately after and following a fall for 4 of 20 residents (R36, R52, R47 and R299) reviewed for quality of care in the sample of 20. The findings include: 1. On 6/9/25 11:35 AM, R36 was lying in bed and had a cast on her right lower leg. R36 said that she had a fall in the bathroom and broke her leg. On 6/10/25 at 10:20 AM, V34 (R36's Spouse) said that he came in on 5/11/25 and R36 was on the floor of the bathroom. V34 said that a male and female staff member came in and lifted her back up into her wheelchair. V34 said that a couple days later, he noticed that her leg was bruised, and her foot was pointed in an abnormal position. On 6/10/25 at 12:19 PM, V22, Certified Nursing Assistant (CNA) said that on 5/11/25, R36 had a fall in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-06-11 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews the facility failed to ensure resident refrigerators were monitored and maintained, and failed to ensure perishable foods were dated which applies to 7 of 7 residents (R33, R55, R67, R65, R298, R199, R80) reviewed for safe food handling in a sample of 20. The findings include: On 6/9/25 at 9:00 AM, R33's room refrigerator thermometer read 55 degrees Fahrenheit (F). The refrigerator had yogurt and other personal food products in it. R33 was eating a yogurt of the same brand at that time. On 6/10/25 at 1:20 PM, R33's refrigerator thermometer read 50 degrees F. V26 Certified Nursing Assistant (CNA) was present at that time and verified the temperature reading on the thermometer. V26 stated they were pretty sure that was too high. On 6/9/25 at 9:15 AM, R55's room refrigerator had no thermometer in it. The refrigerator had 10 small foam food containers with no dates on them. R55 stated their daughter brought food from home for him all the time. R55 did not know how long the different items had been in the refrigerator. On 6/9/25 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-06-11 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. On 6/9/25 at 11:35 AM, R36 was lying in bed. R36 said that she is getting treatment for the wounds on her buttock. R36's room door did not have a sign on it saying she was on EBP (Enhanced Barrier Precautions) nor was there PPE (Personal Protective Equipment) outside of R36's room. On 6/9/25 at 11:37 AM, V7 (Infection Preventionist) put an EBP sign on R36's door and a cart of PPE outside of the door. On 6/9/25 at 2:25 PM, V7 said that she did just put R36's EBP sign on her door that day. V7 said that she was reviewing charts and noticed that R36 came back from the hospital with multiple wounds and should have been placed on EBP upon her re-admission. R36's Physician's Order Sheet printed on 6/9/25 shows that she re-admitted to the facility on [DATE] and an order for EBP for wounds was placed on 6/9/25. R36's Wound assessment dated [DATE] shows that she has an unstageable pressure injury on her left hip, right hip and buttock and a stage 3 pressure injury on her left lower buttock. The facility's Enhanced…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-11 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident's assessment was completed accurately for 1 of 20 residents (R95) reviewed for assessments in the sample of 20. The findings include: R95's Minimum Data Set (MDS) dated [DATE] shows Discharge status: short term General Hospital (acute hospital). R95's Progress Notes dated 3/28/25 at 4:28 PM shows Resident discharged home with granddaughter, to receive home health care. Resident discharged with all scripts, paperwork and belongings. On 06/11/25 at 10:25 AM, V5 Director of Nursing said R95's MDS was done in error, R95 was not hospitalized she went home with family per the progress notes. On 06/11/25 at 11:53 AM, V1 Chief Executive Officer said the facility doesn't have a policy on assessments, they just follow the Resident Assessment Instrument (RAI) procedure and are to submit MDS assessments timely and accurately.
- Potential for harm · Dcited before2025-06-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a resident had a dressing on a pressure injury and failed to ensure pressure prevention interventions were in place for 2 of 6 residents (R47, R299) reviewed for pressure injuries in the sample of 20. The findings include: 1. R47's Wound Assessment Details Report completed on 6/7/25 shows he has a stage 4 pressure injury to his left heel. The report shows his wound measures 1.00 centimeter (cm.) length x 1.00 cm. width x .20 cm. depth with a light amount of drainage. R47's Physician Order Summary shows he has treatment orders for medi-honey and a dry dressing over the wound bed. On 6/9/25 at 9:50 AM, V14 (Wound Care Nurse) and V15 (Wound Care Nurse Practitioner) were completing a wound assessment on R47's left heel wound. When V14 pulled off R47's sock there was no dressing on his left heel. V14 said R47 should have a dressing on his wound and he has orders for dressing changes 3 times a week and as needed. V14 said any nurse can…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-11 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure indwelling urinary catheter bags were kept below the level of the bladder and off of the floor to prevent infections for 2 of 3 residents (R148 and R47) reviewed for indwelling urinary catheters in the sample of 20. The findings include: 1. On 6/9/25 at 9:08 AM, R148 was being transferred from her bed to a shower chair with a mechanical lift. R148 had an indwelling urinary catheter in place with cloudy yellow urine present in the tubing. V19 and V20 (Certified Nursing Assistants) placed a mechanical lift sling under R148. V19 and V20 attached the sling to the mechanical lift and then hung R148's catheter bag on the sling strap which was above R148's bladder. R148's urine in her catheter tubing was seen backflowing into R148's bladder. On 6/10/25 at 11:02 AM, V5 (Director of Nursing) said that urinary catheter bags should always be kept below the level of the bladder. V5 said that hanging the bag from the straps of the mechanical lift sling is not appropriate. R148's Care Plan shows, Position catheter bag…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-11 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to monitor residents to ensure medications were administered completely which applies to 2 of 2 residents (R1, R4) reviewed for medication administration in a sample of 20. The findings include. 1. R1's Facility assessment dated [DATE] showed R1 to be a [AGE] year-old female resident with severe cognitive impairment admitted with diagnoses which included dementia. On 6/9/25 at 10:55 AM, R1 was resting in their wheelchair in the common area near the nurse's station. When R1 went to speak 2 partially dissolved pills fell out of R1's mouth. R1 was appeared very tired and had some confusion when asked when they had taken their pills. On 6/9/25 at 11:00 AM, V29 Registered Nurse stated R1 had received their medications with the morning medication pass around 9 AM. V29 stated they thought R1 had swallowed all their pills. V29 stated they did not check for pocketing after the medications were given. On 6/10/25 at 10:00 AM, V16 Licensed Practical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a call light was within reach for a high fall risk resident which applies to 1 or 6 residents (R1) reviewed for safety in a sample of 16. The findings include: R1's admission Record printed on 3/10/25 showed R1 is an eighty five year old female resident admitted to the facility with diagnoses which include post surgical amputation, reduced mobility, needing assistance with personal care, absence of left leg below the knee. R1's Fall assessment dated [DATE] showed R1 is at High Risk for Falling. On 3/10/25 at 11:50 AM, R1 was sitting in their wheelchair with the bedside table across them eating lunch. R1 stated she was admitted to the facility after having her left lower leg amputated after having blood flow complications in her leg. R1's call light was wrapped around the bed rail on the opposite side of the bed from R1. R1 stated she would not be able to reach that. R1 demonstrated by leaning towards bed. The call light was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure treatment orders were performed for a resident with a stage 3 sacral pressure injury. This applies to 1 of 3 residents (R1) reviewed for pressure injuries in the sample of 6. The findings include: R1's face sheet shows she is a [AGE] year-old female with diagnoses including spinal stenosis, history of falling, quadriplegia, unspecified injury at C4 level of cervical spinal cord, neuromuscular dysfunction of the bladder, neurogenic bowel, reduced mobility, muscle weakness and history of malignant neoplasm of the breast. R1's Wound Progress note dated 8/22/24 documents a stage 3 pressure wound to the sacrum, full thickness, measuring 7.1 cm (centimeters) x 4.5cm x 0.2 cm with moderate serous drainage. R1's Wound Progress note dated 8/29/24 documents a stage 3 pressure wound to the sacrum, full thickness, measuring 3.2 cm x 2.1 cm x 0.2 cm with moderate serous drainage. R1's Medication Administration Record (M.A.R.) dated August 2024 shows treatment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-05-09 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to initiate Enhanced Barrier Precautions (EBP) for residents with an increased risk of contracting a Multi-drug Resistant Organism (MDRO) during high contact activities for 8 of 10 residents (R198, R292, R22, R287, R190, R301, R203, R291) reviewed for infection control in the sample of 14 and 7 residents (R29, R202, R30, R294, R204, R200, R201) outside the sample. The findings include: The facility Matrix provided on 5/7/24 showed the following residents had invasive medical devices and/or pressure ulcers: R287, R198, R291, R190, R202, R30, R301, R203, R201, R22, and R200. The facility's Wound Report dated May 2024 showed the following residents had chronic wounds (pressure ulcers, venous stasis ulcers, or diabetic ulcers): R198, R292, R29, R202, R30, R294, R204, R22, and R200. A facility wide tour was conducted on 5/7/24 and 5/8/24, the residents listed above did not have EBP signs on door, nor did they have an isolation cart with PPE…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 11 citations
- Potential for harm · D2024-05-09 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident received showers for 1 of 1 resident (R203) reviewed for activities of daily living in the sample of 14. The findings include: R203's face sheet printed on 5/8/24 showed an admission date of 4/19/24 and diagnoses including but not limited to multiple sclerosis, quadriplegia, cervical disc disorder, and need for assistance with personal care. R203's facility assessment dated [DATE] showed no cognitive impairment or memory problems. The assessment showed R203 is totally dependent on staff for showers and bathing. The same assessment showed it is very important to R203 to choose between a bath or a shower. On 5/7/24 at 11:00 AM, R203 was lying in bed and covered up to the waist with a light sheet. R203's hair was greasy and uncombed. R203 stated he has not been offered a shower since he was admitted (18 days ago). R203 said staff have quickly wiped him down with peri wipes once or twice but that is about it. R203 said he has…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a physician ordered dressing was in place for a resident at risk for skin breakdown for 1 of 3 residents (R203) reviewed for pressure ulcers in the sample of 14. The findings include: R203's face sheet printed on 5/8/24 showed an admission date of 4/19/24 and diagnoses including but not limited to multiple sclerosis, quadriplegia, cervical disc disorder, and need for assistance with personal care. R203's facility assessment dated [DATE] showed no cognitive impairment or memory problems. The assessment showed R203 is totally dependent on staff for showers, bathing, lower body dressing, and transfers. The same assessment showed R203 is at risk for developing pressure ulcers. R203's pressure ulcer risk assessment dated [DATE] showed a moderate risk. R203's order summary report showed an order start dated 4/23/24 for: Sacrum-cleanse with NS (normal saline), apply foam dressing every day shift every Tues, Thurs, Sat for protection.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-09 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a drainage bag was not laying on the bed, was kept below the level of the bladder, and a dignity bag was used to cover the drainage bag. The facility failed to ensure catheter tubing was not kinked or occluded. This applies to 3 of 3 residents (R287, R22, R190) reviewed for catheters in the sample of 14. The findings include: 1. On 5/7/24 at 9:44 AM, R287 was laying on her back in bed with her catheter tubing kinked and occluded under her right leg. There was cloudy yellow urine present in the catheter tubing. R287 stated she did not know why she had a catheter and has had it since she was in the hospital. On 5/08/24 at 1:34 PM, V2 DON stated there shouldn't be any kinks in the catheter tubing. The resident shouldn't be laying on the tubing because it can cause urinary retention. The urine needs to have good flow to get out and if it doesn't it can lead to a urinary tract infection and sepsis. It puts them at higher risk for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure oxygen was administered at the physician prescribed rate for 1 of 1 resident (R192) reviewed for oxygen in the sample of 14. The findings include: R192's face sheet printed on 5/8/24 showed diagnoses including but not limited to chronic obstructive pulmonary disease, chronic diastolic heart failure, burns, left radius fracture, and hypertension. R192's facility assessment dated [DATE] showed supervision or touch assistance needed from staff for oral hygiene, toileting, showers, and personal hygiene. The same assessment showed no cognitive impairment. R192's order summary report shows a physician order start dated 4/27/24 for: Apply oxygen 2L/min (liters per minute) as needed to keep O2sat (oxygen saturation level) above 92% every shift for sob (shortness of breath). On 5/7/24 at 10:17 AM, R192 was seated in a wheelchair in his room. An oxygen line with the nasal cannula was inserted in his nose. The portable oxygen tank on the back…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-09 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to honor a resident's food preference and find an appropriate alternative for 1 of 1 resident (R300) reviewed for food preferences in the sample of 14. The findings include: On 5/8/24 at 9:14 AM, R300 stated she got eggs this morning for breakfast. R300 stated she can't even stand the smell of eggs; it makes her sick to her stomach. R300 stated she keeps getting eggs for breakfast even though she told staff that she doesn't like them and is allergic to them. R300 stated she just eats the oatmeal that is sent up. On 5/8/24 at 9:25 AM, V13 CNA (Certified Nursing Assistant) stated, R300 is not allergic to eggs; she doesn't like eggs. V13 stated they bring her eggs, and she won't eat them; she usually just eats her oatmeal. V13 stated R300 was not the only resident that doesn't like eggs and doesn't want them. V13 stated there are other residents on the second floor that don't want the eggs. V13 stated they have called the kitchen to let them…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-16 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to assess a resident's skin condition for 1 of 3 residents (R1) reviewed for non pressure skin condition in the sample of 5. The findings include: R1's electronic medical record shows R1 is [AGE] year old with diagnoses of dementia, osteoporosis, and history of falling. On 1/16/24 at 9:45 AM, V3 (Wound Nurse) said there was one resident (R1) that has a skin rash at the facility. This surveyor and V3 checked R1's skin. R1 was noted to have rashes on their buttocks and peri areas. V3 said R1's rashes were due to R1 being incontinent. V4 (R1's daughter) was also with R1. V4 said she now goes to the facility daily to monitor R1's care after R1 was noted to have developed a bad rash at the facility. V4 said R1 sits in her chair for long periods of time. V4 also said she was concerned if R1 was being checked if she was soiled to prevent her from having further rashes. On 1/16/24 at 10:30 AM, V3 (Wound Nurse) said on 1/5/24, he was the one who called…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-07-19 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed ensure staff wore hairnets in the kitchen. The facility failed to store dry foods in a manner to prevent contamination. The facility failed to sanitize/wash dishware in a manner to prevent cross contamination. The facility failed to ensure food storage areas were clean and free of debris. These failures have the potential to affect all 35 residents in the facility. The findings include: The facility's Resident Census and Conditions of Residents form dated July 17, 2023, showed a resident census of 35. On July 17, 2023, at 9:00 AM, V4 Kitchen Aide was observed walking around the kitchen with no hairnet on. V4 walked over to the dishwasher and removed clean dishes from the dishwasher. V4 did not wash her hands or don gloves prior to removing the dishes from the dishwasher. V4 then began rinsing dirty dishes, not wearing any gloves. V4 placed the dirty dishes in the dishwasher. At 9:05 AM, V4 removed the clean dishes from the dishwasher, without washing her hands or donning gloves prior to handling the clean dishes.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-07-19 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure a COVID positive staff member did not provide cares to facility residents. The facility failed to ensure staff wore the recommended personal protective equipment (PPE) when caring for COVID positive residents and during facility testing for COVID-19.These failures have the potential to affect all 35 residents in the facility. The findings include: 1. V8 Certified Nursing Assistant's (CNA) COVID Point of Care Testing Result report dated July 14, 2023, showed V8 tested positive for COVID-19. The report showed V8 was symptomatic with a complaint of fatigue. V8's July 2023 timecard showed V8 clocked into work at 7:12 AM on July 14, 2023 and clocked out of work at 11:24 AM. On July 17, 2023, at 10:07 AM, V3 Registered Nurse/Infection Preventionist (RN/IP) stated, The facility is currently in (COVID-19) outbreak status. The outbreak started on July 3, 2023, when a resident tested positive for COVID. As of last Friday (7/14/23), we have 4 positive residents in our facility. Last Friday, we had a CNA (V8) report…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-07-19 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to follow the recipes, to ensure the nutritive value of pureed foods, for four of four residents (R18, R25, R28, R197) reviewed for pureed diets in the sample of 12. The findings include: The facility's Diet Report dated July 17, 2023, showed R18, R25, R28, and R197 received a pureed diet. The facility's menu dated July 18, 2023, showed a lunch menu that included tuna salad on a croissant. The facility's pureed tuna salad on croissant recipe dated 2020, showed 1 cup of milk should be blended with 4 sandwiches of tuna salad on a croissant to make 4 pureed servings. On July 17, 2023, at 10:25 AM, V5 [NAME] added 4 servings of tuna salad and an unmeasured amount of water to the food processor. No croissants were added to the food processor. V5 blended the tuna salad and water. V5 [NAME] then divided the mixture into 4 separate servings, to be served at lunch, and placed them in the cooler. On July 17, 2023, at 11:48 AM, V6 Dietary Manager delivered pureed food trays to residents. V6 stated, (V5 Cook) did not puree…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-19 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor residents' weight that have a history of weight changes for two of three residents (R28, R25) reviewed for weight change in the sample of 12. The findings include: 1. R28's admission Record shows he was admitted to the facility on [DATE] with diagnoses including traumatic subdural hemorrhage, skull fracture, gastrostomy status, protein-calorie malnutrition, pneumonia, history of falling, cognitive communication deficit, need for assistance with personal care, and dysphagia. R28's Order Summary Report dated July 18, 2023 shows an order for, Weigh every Tuesday and record. R28's Dietary Note dated March 8, 2023 shows he was seen at bedside by registered dietitian for significant weight loss. R28's Weights and Vitals Summary shows he was weighed on March 21, 2023, April 26, 2023, May 9, 2023, June 17, 2023, and July 8, 2023. R28 weighed 152.8 pounds on March 21, 2023 and on July 8, 2023 R28 weighed 147.8 pounds. (Five pound weight loss) On July…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-19 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to administer medications as ordered. There were 29 opportunities with 5 errors resulting in a 17.24% error rate. The findings include: 1. On July 17, 2023 at 9:14 AM, V10 Registered Nurse (RN) was giving R21's his scheduled morning medication. She did not give R21 his scheduled senna-docusate (stool softener), thiamine (vitamin B-1) and hydrocortisone cream (anti-itch cream). When V10 RN gave R21 his morning medications he had a scheduled Lidoderm (pain patch) patch to his lower back. She had to remove his old Lidoderm patch to apply the new one. The old Lidoderm patch was dated July 16, 2023 (the day before). R21's Medication Administration Record (MAR) for July 2023 shows, Senna-Docusate sodium oral tablet 8.6-50 MG (milligram), give 2 tablet by mouth in the morning for constipation. Thiamine HCL (hydrochloric acid) oral tablet 100 mg, give 1 tablet by mouth one time a day for supplement. Hydrocortisone external cream 1%, apply to rt (right) lower back, rt (right) hip, leg topically every 12 hours for rash.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record. 1 Medicare payment denial on record.
- Medicare payment denial — starting 2025-07-05 for 58 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| NEW SUMMIT REHABILITATION AND HEALTHCARE HOLDINGS, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 05/20/2024 |
| CROOK, IAN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 05/20/2024 |
| BARTEL, JESSICA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2024 |
| KANEV, LEO | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2024 |
CMS files one row per role, so the 10 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.8M paid to related parties — landlords or management companies under common ownership — equal to about 17% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 146179. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-11, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.