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Avantara Aurora

400 West Sullivan Road, Aurora, IL 60506 · For profit - Limited Liability company · 87 certified beds · (630) 859-3700 Medicare & Medicaid certified

Call the home — (630) 859-3700 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)
  • about 18% 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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1315 N Highland Ave · (630) 906-1800 · Call to confirm hours
Pharmacy
Oportun0.5 mi
1248 N Lake St · (331) 481-8826 · Call to confirm hours
Grocery
1250 N Lake St · (630) 947-0100 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

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 5 of 5
Short-stay residentsrehab / post-hospital 3 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 improved from 3 to 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.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased5.8%13.4%15.4%better
Long-stay residents who lose too much weight2.5%6.3%5.4%better
Long-stay residents with a catheter left in their bladder2.2%0.9%0.9%worse
Long-stay residents with a urinary tract infection0.5%1.5%2.0%better
Long-stay residents with depressive symptoms95.9%54.2%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury0.9%3.1%3.3%better
Long-stay residents whose ability to walk worsened10.9%14.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication16.7%18.3%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%91.8%95.3%typical
Long-stay residents with pressure ulcers1.3%4.8%4.7%better
Long-stay residents with worsening bladder/bowel control20.9%20.6%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table7.6%21.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.3%2.2%1.4%better
Short-stay residents given the seasonal flu vaccine89.6%63.1%79.4%better
Short-stay residents rehospitalized after admission26.1%26.1%22.6%worse
Short-stay residents with an outpatient ER visit17.2%13.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.202.021.67worse
Long-stay outpatient ER visits per 1,000 resident days0.612.221.80better

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.

52.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 180 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

52.1%U.S. median 51.5%
Got home and stayed home
10.8%U.S. median 10.7%
Went back to hospital
48.0%U.S. median 56.6%
Met the expected recovery
0.33U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 48.0% 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 77 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 0.33 therapist hours per resident per day in 2026Q1 — more than 54% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 30% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF52.1%CMS range 44.6–58.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.8%CMS range 8.3–14.710.7%Oct 2022–Sep 2024no 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 discharge48.0%56.6%Oct 2024–Sep 2025CMS 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 discharge46.8%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge33.8%50.0%Oct 2024–Sep 2025CMS 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 identified100.0%98.7%Oct 2024–Sep 2025CMS 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 setting100.0%100.0%Oct 2024–Sep 2025CMS 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 discharge100.0%98.7%Oct 2024–Sep 2025CMS 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 stay0.9%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.5%CMS range 4.9–11.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.061.02Oct 2022–Sep 2024CMS 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

1.22
RN hours/ resident / day
0.19
LPN hours/ resident / day
2.05
Aide hours/ resident / day
3.46
Total nurse hours/ resident / day
1.16
RN hoursweekends
52.6%
Total nursing turnover
21.1%
RN turnover

How full it usually is: this home is certified for 87 beds and averages 77.0 residents a day — about 89% occupied, or roughly 10 beds typically open. It runs fairly full. 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 3.46 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 1.22 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.05 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 3.36 hrs/resident/day on weekends vs 3.50 on weekdays — 4% thinner on weekends. RN hours go from 1.24 to 1.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 53% 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

10
deficiencies at the latest standard inspection (2026-05-14)
7
at the previous standard inspection (2025-03-14)

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.

ABCDEFGHIJKL

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.

23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.

  • Actual harm · Gcited before2024-04-11 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide 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 observation, interview, and record review, the facility failed to follow physician's orders and weigh a resident weekly. The facility also failed to implement interventions for residents with weight loss. This failure resulted in R76 having a significant weight loss. This applies to 5 of 7 residents (R76, R40, R13, R10, and R53) reviewed for weight loss in the sample of 20. The findings include: 1. The EMR (Electronic Medical Record) showed R76 was admitted to the facility on [DATE], with multiple diagnoses including stroke, type 2 diabetes, protein-calorie malnutrition, dysphagia, and gastrostomy status. R76's MDS (Minimum Data Set) dated March 23, 2024, showed R76 had moderate cognitive impairment. R76's nutrition care plan dated March 28, 2024, showed, Resident is at risk for alteration in nutritional status related to tube feeding, dysphagia. The care plan continued to show multiple interventions dated March 28, 2024, including Obtain weight as ordered. R76's order summary report dated April 10,…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-20 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    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 maintain the building environment and plumbing equipment in good repair by ensuring water pipes connected to resident toilets were free from leaks. This applies to 2 of 3 residents (R1 and R3) reviewed for toilet leaks. The findings include:Review of the Electronic Medical Record (EMR) showed that R1 was an [AGE] year-old female admitted to the facility on [DATE], with diagnoses including reduced mobility, neuropathy, polyarthritis, and a stage 2 sacral pressure ulcer. R1 resided in room [ROOM NUMBER] until she was hospitalized on [DATE], and subsequently transferred to another facility.On May 19, 2026, at 10:30 A.M., an environmental tour of room [ROOM NUMBER] was conducted with the V2 (Assistant Director of Nursing). The room was occupied by a new resident, R4, who was observed in a reclining wheelchair wearing a cervical collar. R4 stated he was wearing the collar due to a broken neck sustained from a recent fall and noted that he…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-05-14 · tag F0628 — pattern
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    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 notify the Long-Term Care Ombudsman facility representative of non-emergent transfer and discharges monthly as the agency requested. This applies to 4 of 4 residents (R9, R12, R88, R89) reviewed for discharge in the sample of 23. The findings include:1.R89's EMR (Electronic Medical Record) showed R89 was admitted to the facility on [DATE], and discharged on February 14, 2026. R89 was selected for closed record planned discharge review. On [DATE], at 11:41 AM, V28 (Social Services Assistant) stated R89 was discharged back to the community senior living apartment, where she resided previously. Requested evidence of notification of discharge to the Long-Term Care Ombudsman representative and V28 referred surveyor to V3 (Assistant Administrator).On [DATE], at 11:45 AM, V3 stated the notification to the ombudsman occurs through email notification. V3 provided email notification of R89's discharge that occurred on [DATE], at 11:43 AM. V3 stated the last…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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 provide grooming/hygiene for a resident who required assistance for ADL (Activities of Daily Living) care.This applies to 1 of 1 resident (R43) reviewed for ADL care in the sample of 23. The findings include:On May 11, 2026, at 11:47 AM, R43 was in bed. R43 had about 0.5 to one CM (centimeters) long facial mustache and chin hair. R43 said she doesn't like facial hair and would like to get it shaved, but she couldn't do it by herself.On May 12, 2026, at 11:21 AM, R43 was in bed and still had the same facial hair. R43 said she asked, but no one assisted her with shaving her facial hair. R43 said she forgot the name of the staff she asked to assist her with shaving her facial hair.On May 13, 2026, at 2:41 PM, R43 was in bed and still had the same facial hair. R43 said she asked one of the CNAs (Certified Nursing Assistants) to assist her with shaving her facial hair, but they still haven't done so.According to the EMR (Electronic Medical…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 interview and record review, the facility failed to provide necessary assistance and supervision during toileting, for a resident that had limited ability to sit unsupported, was cognitively impaired, with known impulsivity, and at high risk for falls, to prevent a fall that resulted in injury. This applies to 1 of 2 residents (R9) reviewed for falls in the sample of 23. R9's EMR (Electronic Medical Record) showed R9 was readmitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non dominant side, kidney transplant status, type 2 diabetes, abnormal posture and hypertensive heart disease.R9's MDS (Minimum Data Set) dated April 23, 2026, showed R9 was severely cognitively impaired and required assistance with ADL's including supervision with eating and oral hygiene, substantial assistance with upper body dressing, bed mobility and transfer, and dependent on staff for toileting, bathing, and lower body dressing. R9's…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-14 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    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 perform a nutrition assessment and implement interventions for a resident experiencing poor appetite and oral intake, hyperkalemia, and significant weight loss. This applies to 1 of 1 residents (R1) reviewed for nutrition in a sample of 23. The findings include: Social Services progress note, dated May 11, 2026, shows R1's cognition was intact. Hospital nephrology note, dated April 9, 2026, shows R1 experienced hyponatremia, volume overload with edema, high blood potassium, acute kidney injury, and required temporary hemodialysis with her last dialysis treatment on April 2, 2026. Review of R1's Care Plan shows R1 was at risk alteration in nutritional status related to congestive heart failure and morbid obesity and approaches included monitoring for weight loss, obtaining and reporting abnormal labs, weigh as order, and provide diet as order. R1's fluid care plan showed R1 was at risk for adverse reactions related to dehydration or potential fluid deficit due to congestive heart failure, hypertension and…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-14 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    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 develop an effective analgesic regimen, reassess a residents unrelieved pain, develop a care plan for pain management or notify the physician of unrelieved pain in accordance with facility policy.This applies to 1 of 1 resident (R94) reviewed for pain management.The Findings include:R94's, EMR (Electronic Medical Record) showed R94 was[AGE] years old and admitted to the facility on [DATE], with multiple diagnoses including end stage renal disease with dependence on hemodialysis, aftercare follow a right hip replacement, diabetes type 2 and Barrett's esophagus disease.R94's BIMs (Brief Interview for Mental Status) assessment dated [DATE], showed R94 was cognitively intact. On May 11, 2026, at 11:01 AM, R94 was sitting up in bed, using foam abduction pillow between both legs and stated she is uncomfortable when sitting up in a chair and especially uncomfortable while in dialysis. R94 explained that she recently had hip surgery.On May 14,…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-14 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide 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

    Based on observation, interview and document review, the facility failed to follow their policy for proper controlled medication documentation, storage, and disposal.This applies to 2 of 4 residents (R40, R98) reviewed for controlled medication storage, labeling, and disposal in the sample of 23. Findings include:1. On May 13, 2026, at 2:38 PM, The facility's medication storage room was inspected in the presence of V20 (Nurse). V20 opened the medication storage refrigerator and there was a clear locked box that contained an unopened box of controlled medication (30 milliliters of morphine). V20 said she was new at the facility and was not aware there was any controlled medication stored in the refrigerator. The controlled medication box had a medication label that showed R98's name. V20 said she had worked two shifts on the unit, and they did not account for the controlled medication in the refrigerator at the beginning and end of shifts. V20 looked in the EMR (Electronic Medical Records) and said R98 was discharged from the facility on December 23, 2025. 2. On May 14, 2026, at 2:06…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-14 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure 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 26 medication opportunities with 2 errors resulting in a 7.69% medication error rate. This applies to 2 of 6 residents (R16, R29) observed for medication administration in the sample of 23. The findings include:1. On May 12, 2026, at 11:28 AM, V17 checked the medication order on the EMAR (electronic medication administration records), which stated, Difluprednate ophthalmic emulsion 0.05 percent, instill one drop in the right eye four times a day for post-cataract surgery. V17 removed an eye drop medication from the medication cart; the label on the bag matched the order exactly. V17 administered one drop of the eyedrops to R29's right eye; it got onto R16's eyelash, and V17 administered another drop to R29's right eye. V17 was inserting the eye drop bottle in the medication bag, and the eye drop bottle label V17 administered to R29 showed, brinzolamide suspension one percent ophthalmic. V17 said she only checked the label on the eye drops bag, did not check the…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-14 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    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 their policy for proper medication storage and labeling.This applies to 2 of 4 residents (R29, R43) reviewed for medication storage and labeling in the sample of 23. Findings include:1. On May 14, 2026, at 1:40 PM during medication cart inspection with V2 (Director of Nursing/ DON), R43's controlled medication (hydrocodone-APAP 5-325 MG tablet) bingo card pocket three were popped open with the tablet exposed. V2 said medications should not be left exposed and should have been disposed of by two nurses for infection control and to prevent medication diversion.2. On May 12, 2026, at 11:28 AM, during medication administration, a wrong eye drop medication not ordered for R29 was stored in R29's eyedrop medication bag with the correct pharmacy label. V17 administered the wrong eye drop to R29. R29's eye drops medication label and medication order showed, Difluprednate Ophthalmic Emulsion 0.05 percent. V17 administered an eye drop medication, Brinzolamide Suspension one percent Ophthalmic into R29's right…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-14 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    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 serve portions of pureed pork in amounts indicated on the planned/approved facility menus. This applies to 2 of 2 residents (R73 and R99) reviewed for pureed diets in the sample of 23. The findings include:Facility document, dated May 14, 2026, shows R73 and R99 had physician orders for pureed diets. On May 12, 2025 at 11:47 AM during lunch service, V26 (Cook) provided one #8 scoop (4 fluid ounces) of pureed pork on each plate when serving two pureed diet lunches. When questioned regarding the serving size, V25 (Food Service Director) examined the diet spread sheet and stated the serving size pureed pork planned on the menu was 2-#10 scoops (approximately 7 fluid ounces total). V25 stated the first two pureed plates did not have enough pureed pork and instructed V26 to provide the third pureed plate with 2-#8 scoops (8 fluid ounces) of pureed pork. After the third/final plate of pureed pork was served, V26 used the #8 scoop and retrieved approximately 6 fluid ounces of pureed pork from the pan on the…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · Dcited before2026-05-14 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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 follow their policy for contact isolation precaution and infection prevention practices during medication administration.This applies to 2 of 7 residents (R83, R93) reviewed for infection control in the sample of 23. Findings include:1. R93's POS (Physician Order Summary) dated May 4, 2026, showed an active order for Strict Contact Isolation for (positive) C-Diff [Clostridioides difficile - a bacteria that causes life-threatening diarrhea] every shift. The same POS also showed an order for Vancomycin HCI Oral Capsule 125 MG (Milligram), give one capsule by mouth four times a day for C-Diff for 10 days, start date: May 4, 2026, and end date: May 14, 2026.On May 11, 2026, at 12:49 PM, R93 had a sign on the door that says, STOP. CONTACT PRECAUTIONS. EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before entry. Discard gloves before room exits. Put on a gown before room entry. Discard gown before room exit. V18 (Regional Guest…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-03-14 · tag F0803 — failed to meet residents' dietary needs — widespread
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    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 their planned menu resulting in lunch entrees being served to residents with inadequate protein. This applies to all 78 residents in the facility receiving General, Low Concentrated Sweets, No Added Salt, Pureed, and Mechanical Soft diets at the facility. The findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 3/14/25 documents that the total census was 79 residents. The facility's Order Listing Report of 3/12/25 showed 1 NPO (nothing by mouth) resident. The facility's Daily Spreadsheet, dated Week 1 Wednesday, shows residents with General, Mechanical Soft, Pureed, No Added Salt, Low Concentrated Sweets all received either regular, ground or pureed portions of ham. The spread sheet shows each resident receiving the ham were to be served the equivalent of a 3-ounce portion of ham. On 3/12/25 at 11:50 AM, V24 (Cook) was observed plating food for a regular diet, and she placed one slice of ham on the…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-03-14 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    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 properly secure resident medications. This applies to 5 out of 5 residents (R15, R22, R24, R40, R43) reviewed for medications in a sample of 24. The findings include: 1. On 3/11/2025 at 10:17 AM and 3/12/2025 at 12:22 PM, a medication cup with 2 capsules of fish oil and 1 capsule of turmeric was observed on R43's bed side table. She said she usually takes the medication when her tummy feels better because she had hyperacidity. R43 said nurses usually leave the medication there so she can take it when she wants to. Review of R43's POS (Physician Order Sheet) shows order for fish oil and turmeric but there are no orders for resident to self-administer medication and medication to stay at the bedside. On 3/13/25 at 12:10 PM, V2 said there are no residents with orders for medication to stay at the bedside, no orders to self-administer medication. She said she expects nurses to take unlabeled medication from resident rooms. She said if a resident wants to take medication, nurses should ask order from physician. 2.…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-03-14 · tag F0880 — failed to prevent and control infections — pattern
    Provide 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 implement transmission-based precautions for a resident with an acute contagious gastrointestinal infection and adhere to enhanced-barrier precautions. This applies to 6 out 6 residents (R184, R183, R65, R51, R46, and R40) reviewed for infection control in a sample of 24. The findings include: 1. On 3/11/25 at 12:06 PM there was no isolation sign on the door to R183 & R184 shared room. R183 was in her wheelchair very upset saying that she has had 3 bowel movements in her brief since she was in physical therapy, and nobody has come to change her brief. R183 said that she has been having diarrhea for the last week. On 3/12/25 at 11:08 AM, CNA (Certified Nurse's Assistant) said that R183 has been having loose stools for at least the last four days. On 3/13/25 at 11:27 AM, V2 DON (Director of Nursing) said that R183 has had loose stools for about a week and that R183 was started on antibiotics on Friday 3/7/25 for pneumonia and the antibiotics can cause loose stools and C diff (acute contagious gastrointestinal…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-14 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    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 treat residents with dignity while providing care. This applies to 2 of 2 residents (R183 and R184) reviewed for dignity in a sample of 24. The findings include: 1. On 03/11/25 at 12:46 PM, V15 (Nurse) was standing over R184 feeding her. On 3/12/25 at 12:37 PM V15 said that she shouldn't have stood over R184 while feeding her because it is a dignity issue. 2. On 03/12/25 at 10:43 AM V15 (Nurse) entered R183's room after knocking. V18 CNA (Certified Nurses' Assistant) and V19 (R183's Daughter) were providing incontinence care for R183 and the curtain was not pulled. R183 was naked from the waist down and could be seen from the hall. On 03/12/25 at 11:33 AM, R183, who's cognition is intact, said that she wants the curtain and the door closed while staff are providing care for her. On 03/12/25 at 11:17 AM V18 CNA (Certified Nurse's Assistant) said that she should have closed R183's curtain to provide privacy. On 03/13/25 at 11:27 AM V2 DON (Director of Nursing) said that V15 should not have been standing over…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-14 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, facility failed to implement measures to prevent re-opening of pressure ulcer for a resident with known skin alterations to the right buttocks and coccyx. The facility also failed to then assess, report, and initiate pressure ulcer treatments. This applies to 1 out of 1 (R40) resident reviewed for pressure ulcer in a sample size of 24. The findings include: On 03/11/25 at 02:24 PM, during incontinent care, a wound dressing was noted on R40's right buttock. Multiple open areas were noted on R40's coccyx. R40 did not have any wound dressing on his coccyx. Wound on right buttock appeared red in color with yellow tissue noted around the wound area. Wounds on his coccyx appeared red in color with whitish tissue noted in the wound. R40 appeared frail, unable to fully bend knee and is totally dependent on staff for bed mobility, transfers, and incontinence care. R40 transfers from bed to wheelchair using the mechanical lift. On 3/11/25 at 2:40 PM, V6 (RN-Registered Nurse) provided wound care to R40. V6 measured R40's wounds. Wound on…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-14 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    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 enteral feeding as ordered, and failed to change and label enteral feeding tube equipment for residents receiving gastrostomy tube feedings. This applies to 3 out of 4 (R46, R11, and R23) reviewed for enteral feeding in a sample of 24. The findings include: 1. On 3/12/2025 at 11:30 AM, R46 said he was receiving gastrostomy tube (g-tube) feedings. R46's g-tube pump had an opened but unlabeled bottle of Jevity 1.5 that was connected to a bag of water that was dated 3/10/2025 (two days earlier). The feeding's tubing tip was uncovered. On 3/13/2025 at 8:45 AM, R46's g-tube pump was hanging an opened bottle of feeding dated 3/13/2025 without an opened time. The feeding's connected bag of water was dated 3/10/2025 (three days earlier). The feeding's tubing tip was uncovered. At 12:15 PM, V20 (Agency Registered Nurse/RN) said she was going to administer R46's scheduled bolus g-tube feeding via a pump. V20 said she reviewed R46's order and determined she had to administer a total of 200 ml (milliliters).…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-14 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    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 change a resident's PICC (Peripherally Inserted Central Catheter) line dressing as ordered. This applies to 1 out of 3 residents (R51) reviewed for central intravenous (IV) lines in a sample of 24. The findings include: On 3/11/2025 at 10:45 AM, R51 said he was receiving IV antibiotic infusions for his right foot wound infection. R51 had an intravascular (IV) central catheter to his left upper arm. R51's IV catheter had a transparent dressing dated 3/03/2025 (eight days earlier). The right lower corner of R51's transparent PICC line dressing was loose and no longer adherent to his skin. At 11:10 AM V9 (Registered Nurse/RN) said she was going to infuse R51's scheduled IV antibiotic. V9 initiated R51's IV infusion and failed to assess the dressing's integrity. On 3/13/2025 at 10:25 AM V3 (Assistant Director of Nursing/ADON) said central catheter dressings should be changed every 7 days and as needed (PRN) for infection control and prevention. V3 said nurses should assess PICC line dressings every shift to ensure…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-04-11 · tag F0803 — failed to meet residents' dietary needs — widespread
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    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 their planned menu/recipes resulting in lunch entrees being served to residents with inadequate protein. This applies to all 66 residents in the facility receiving General, Low Concentrated Sweets, No Added Salt, Pureed, and Mechanical Soft diets at the facility. The findings include: Long-Term Care Facility Application for Medicare and Medicaid, dated April 8, 2024, showed the facility census was 71 residents. Client List Report, printed April 9, 2024, showed all but five residents in the facility received either a General, Low Concentrated Sweets, No Added Salt, Pureed or Mechanical Soft diet. Facility Daily Spreadsheet, dated Week 2 Monday, shows residents with General, Mechanical Soft, Pureed, No Added Salt, Low Concentrated Sweets all received either regular, ground or pureed portions of Chicken Alfredo. The spread sheet shows each resident receiving the Chicken [NAME] were to be served the equivalent of a six fluid ounce portion of chicken with [NAME] sauce and a separate 1/2 cup equivalent of…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-11 · tag F0880 — failed to prevent and control infections — pattern
    Provide 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 perform hand hygiene before and after providing direct care to residents on EBP (enhanced barrier precaution). The facility also failed to implement EBP for residents with implanted medical devices, and during high-contact resident care. This applies to 4 of 20 residents (R18, R25, R60 and R76) reviewed for infection control in the sample of 20. The findings include: 1. R18 had multiple diagnoses including chronic respiratory failure with hypoxia, end stage renal failure and dependence on renal dialysis, based on the face sheet. On April 9, 2024 at 10:30 AM, V14 (LPN/Licensed Practical Nurse) was inside the unit nursing station. V14 was on her computer and stated that she was preparing R18's papers because the resident was going out for dialysis. V14 then walked towards R18's room and went inside. An EBP sign was posted on R18's front door. The EBP sign showed, to clean hands, including before entering and leaving the room, wear gloves and…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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 assist residents identified as needing assistance with personal hygiene. This applies to 3 of 3 residents (R12, R60 and R61) reviewed for ADLs (activities of daily living) in the sample of 20. The findings include: 1. R12 had multiple diagnoses including Parkinson's disease with dyskinesia without mention of fluctuations and altered mental status, based on the face sheet. R12's quarterly MDS (minimum data set) dated February 27, 2024 showed that the resident was moderately impaired with cognition and required assistance from the staff with regards to personal hygiene. On April 8, 2024 at 11:43 AM, R12 was inside his room, sitting in his wheelchair. R12 was alert and verbally responsive. R12 had accumulation of long facial hair (beard and mustache). R12 stated that he needed assistance from the staff to shave his beard and trim his mustache. V9 (Licensed Practical Nurse/LPN) was made aware of R12's request to have his beard shaven and…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-04-11 · tag F0908 — failed to keep essential equipment working — widespread
    Keep all essential equipment working safely.
    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 maintain the kitchen floor to ensure cleanability. This applies to all 70 residents in the facility receiving oral diets at the facility. The findings include: Long-Term Care Facility Application for Medicare and Medicaid, dated April 8, 2024, showed the facility census was 71 residents. Client List Report, printed April 9, 2024, showed only one resident did not receive an oral diet at the facility. On April 8, 2024 at 10:29 AM with V12 (Food Service Manager) during the initial kitchen tour, the kitchen floor under the dish machine, in the janitor area, under the cooking hood and cooking equipment, and near the cooler was in poor repair and had a large amount of loose, chipped and crumbled floor debris, as well as food debris, in the areas of disrepair. On April 10, 2024 at 2:24 PM, V18 (Maintenance Director) stated he was aware that the kitchen floor was chipping, crumbling, and in poor repair. V18 stated he was in discussions with the corporate office on how to repair the kitchen floor. Facility policy…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to LEGACY HEALTHCARE — 89 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 52.9+1.1 vs chain
Health inspection 4 of 52.8+1.2 vs chain
Staffing 2 of 52.5-0.5 vs chain
Quality measures 4 of 53.3+0.7 vs chain
The other 88 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Avantara ArrowheadRapid City, SD 1 of 5Avantara Evergreen ParkEvergreen Park, IL 1 of 5Avantara MilbankMilbank, SD 1 of 5Avantara Saint CloudRapid City, SD 1 of 5Avantara WatertownWatertown, SD 1 of 5Emmetsburg Care CenterEmmetsburg, IA 1 of 5Grove Of Elmhurst, TheElmhurst, IL 1 of 5Harmony Cedar RapidsCedar Rapids, IA 1 of 5Harmony House Health Care CenterWaterloo, IA 1 of 5Harmony MarshalltownMarshalltown, IA 1 of 5Harmony WaterlooWaterloo, IA 1 of 5Harmony West Des MoinesWest Des Moines, IA 1 of 5Nexus at BerwynBerwyn, IL 1 of 5Northgate Care CenterWaukon, IA 1 of 5Park View Rehabilitation CenterSac City, IA 1 of 5Southfield Wellness CommunityWebster City, IA 1 of 5Warren Barr South LoopChicago, IL 2 of 5Avantara GrotonGroton, SD 2 of 5Avantara HuronHuron, SD 2 of 5Avantara Lincoln ParkChicago, IL 2 of 5Avantara Mountain ViewRapid City, SD 2 of 5Avantara Palos HeightsPalos Heights, IL 2 of 5Avantara PierrePierre, SD 2 of 5Avantara RedfieldRedfield, SD 2 of 5Bella Terra BloomingdaleBloomingdale, IL 2 of 5Bella Terra Morton GroveMorton Grove, IL 2 of 5Carlton At The Lake, TheChicago, IL 2 of 5Chalet Living & RehabChicago, IL 2 of 5Colonial Manor of ElmaElma, IA 2 of 5Hallmark Care CenterMount Vernon, IA 2 of 5Harmony DavenportDavenport, IA 2 of 5Harmony DubuqueDubuque, IA 2 of 5Harmony PalosPalos Heights, IL 2 of 5Harmony Utica RidgeDavenport, IA 2 of 5Heritage Care And Rehabilitation CenterMason City, IA 2 of 5Manor House Care CenterSigourney, IA 2 of 5Peterson Park Health Care CtrChicago, IL 3 of 5Avantara LibertyvilleLibertyville, IL 3 of 5Avantara NorthRapid City, SD 3 of 5Bloomfield Care CenterBloomfield, IA

Showing 40 of 88; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
DOROS GENERATION TRUST U/A/D 1/3/12Organization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF43%since 11/01/2020
GPN FAMILY TRUST U/A/D 4/28/08Organization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF43%since 11/01/2020
OAKWAY OPERATIONS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST15%since 11/01/2020
AURORA PROPERTY HOLDINGS, LLCOrganization5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 11/01/2020
FORBRIGHT BANKOrganization5% OR GREATER SECURITY INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 07/31/2024
SHABAT, MENACHEMIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2020
LEGACY HEALTHCARE FINANCIAL SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2020
CLEARY, ASHLEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2020
KOUL, SUNITAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2020
MILLER COOPER & CO, LTDOrganizationADP OF THE SNFsince 01/01/2024

CMS files one row per role, so the 19 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

7 organizational owners 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.

$8.9M
Net patient revenuemost recent cost report
-0.5%
Operating marginrevenue minus expenses
$1.6M
Related-party expense18% of expenses
Who pays — share of resident-days
Medicaid 67%Medicare 13%Other / private 20%

This home reported $1.6M paid to related parties — landlords or management companies under common ownership — equal to about 18% 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.

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

$362per resident / day
operating cost
$11,014per month
≈ monthly operating cost
$360per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Illinois
$8,304/mo
Nursing home (semi-private)
$9,216/mo
Nursing home (private)
$6,219/mo
Assisted living

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 145944. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-14, 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.

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