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Grove Of Fox Valley,the

1601 North Farnsworth Avenue, Aurora, IL 60505 · For profit - Individual · 158 certified beds · (630) 898-1180 Medicare & Medicaid certified

Call the home — (630) 898-1180 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0604, F0610) — most recent Apr 20262 actual-harm citations
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
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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) 3 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2635 Church Rd Ste 201 · (630) 315-8700 · Call to confirm hours
Pharmacy
1281 N Farnsworth Ave · (618) 508-4647 · Call to confirm hours
Grocery
1245 Corporate Blvd · (630) 879-8100 · Call to confirm hours
Park
McClure Rd · 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 3 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 2 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.

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 increased2.6%13.4%15.4%better
Long-stay residents who lose too much weight3.4%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 infection0.0%1.5%2.0%better
Long-stay residents with depressive symptoms98.5%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 injury2.8%3.1%3.3%better
Long-stay residents whose ability to walk worsened8.3%14.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication13.8%18.3%18.9%better
Long-stay residents given the seasonal flu vaccine95.4%91.8%95.3%typical
Long-stay residents with pressure ulcers4.6%4.8%4.7%typical
Long-stay residents with worsening bladder/bowel control16.6%20.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table19.0%21.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication3.4%2.2%1.4%worse
Short-stay residents given the seasonal flu vaccine45.2%63.1%79.4%worse
Short-stay residents rehospitalized after admission31.2%26.1%22.6%worse
Short-stay residents with an outpatient ER visit16.1%13.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.692.021.67worse
Long-stay outpatient ER visits per 1,000 resident days4.162.221.80worse

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.

46.0% 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 99 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

46.0%U.S. median 51.5%
Got home and stayed home
10.2%U.S. median 10.7%
Went back to hospital
60.6%U.S. median 56.6%
Met the expected recovery
0.20U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 60.6% 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 33 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 0.20 therapist hours per resident per day in 2026Q1 — more than 21% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% 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 SNF46.0%CMS range 35.5–59.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.2%CMS range 6.3–14.510.7%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 discharge60.6%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 discharge48.5%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 discharge60.6%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 stay2.5%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 hospitalization6.7%CMS range 4.1–10.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.391.02Oct 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

0.94
RN hours/ resident / day
0.60
LPN hours/ resident / day
1.84
Aide hours/ resident / day
3.38
Total nurse hours/ resident / day
0.84
RN hoursweekends
40.5%
Total nursing turnover
25.0%
RN turnover

How full it usually is: this home is certified for 158 beds and averages 124.4 residents a day — about 79% occupied, or roughly 34 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 3.38 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.94 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.84 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 3.26 hrs/resident/day on weekends vs 3.43 on weekdays — 5% thinner on weekends. RN hours go from 0.98 to 0.84 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 40% 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

4
deficiencies at the latest standard inspection (2026-03-27)
6
at the previous standard inspection (2025-01-09)

Deficiencies are fewer than at the previous inspection — improving. 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.

26 citations, most serious first. The 12 most serious are shown; the remaining 14 are one tap away and print in full.

  • Actual harm · Gcited before2026-04-18 · 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 observation, interview and record review, the facility failed to protect a resident dependent on staff for all ADLs (Activities of daily Living), from obtaining full thickness burns on the left side of her torso and partial thickness burns that extended from left upper back to top of the left thigh. This applies to 1 of 3 residents (R1) reviewed for wound care in the sample of 5. This failure resulted in R1 being transferred from the facility to the local emergency room on March 22, 2026, and then transferred to the regional specialty burn center. R1 was admitted to the regional burn center from March 23 through March 26, 2026, with 3% full thickness burns to the left abdomen/flank area with partial thickness burns surrounding the 2 areas of full thickness burn wounds from the left upper back to the left upper thigh. The Findings include:On April 17, 2026, at 4:02 PM, V18 (APN-BC, Advanced Practice Nurse, Board Certified from the Regional Burn Center) stated R1's burn injuries included 2 separate full…

    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
  • Actual harm · Gcited before2023-09-14 · 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 follow a resident's plan of care for transfers for one of three residents (R1) reviewed for transfers on the sample list of three. This failure resulted in R1's foot getting stuck on the front of R1's wheelchair and R1's foot fracture. The findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including cerebral palsy, fracture of right tibia, end stage renal disease, benign prostatic hyperplasia, and atrial fibrillation. R1's MDS (Minimum Data Set) dated May 26, 2023, showed R1 was cognitively intact. The MDS shows R1 required extensive assistance of facility staff for transfers between surfaces. R1's ADL (Activities of Daily Living) care plan dated November 17, 2022, showed, [R1] has an ADL self-care performance deficit and impaired mobility related to cerebral palsy, end stage renal disease, coronary artery disease, atrial fibrillation, anemia, and fracture of shaft of 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-18 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    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 thoroughly investigate the circumstances surrounding an injury of unknown origin, in accordance with facility policy, when a resident dependent on staff assistance for all ADL's (Activities of Daily Living) sustained a burn injury to the left side of her body. This applies to 1 of 3 residents (R1) reviewed for wounds in the sample of 5. The findings include:The facility filed a final report dated March 27, 2026, regarding an injury of unknown origin sustained by R1. The report showed V1 (Administrator) was informed by V2 (Director of Nursing) on March 23, 2026, that R1 had been hospitalized for medical evaluation of redness and open area to her abdomen and redness to her left flank area. R1's MDS (Minimum Data Set) dated April 1, 2026, showed R1 was severely cognitively impaired and required substantial assistance with oral hygiene, rolling side to side in bed, and upper body dressing and dependent on staff for lower body dressing, bathing, toileting,…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-18 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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 maintain urology recommendations for catheter changes, failed to prevent urinary tract infection, failed to change a catheter when needed, and failed to complete comprehensive assessment for indication of catheter use for residents with indwelling urinary catheter. This applies to 2 of 3 residents (R2 and R3) reviewed for catheter use in the sample of 5. The findings include:1. R2's EMR (Electronic Medical Record) showed R2 was admitted to the facility on [DATE], with multiple diagnoses including diabetes type 2, hemiplegia affecting the left non dominant side, benign prostatic hypertrophy, and chronic obstructive pulmonary disease. R2's MDS (Minimum Data Set) dated March 26, 2026, showed R2 was severely cognitively impaired and required assistance with ADLs including substantial assistance with eating, oral hygiene, personal hygiene and upper body dressing, and dependent on staff for toileting, bathing, lower body dressing, bed mobility…

    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 · E2026-03-27 · 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 implement hand hygiene, wear PPE (personal protective equipment) when rendering care and handling linen. This applies to 5 of 5 (R59, R75, R22, R27, and R66) residents reviewed for infection control in sample 25. The findings include:. 1.R59's EMR (Electronic Medical Record) showed R59 was admitted to the facility on [DATE], with diagnosis of peripheral vascular disease, hypertensive heart disease, acquired absence of right leg below knee, anemia, and retention of urine. On 3/25/2026, at 8:58 AM V4 CNA (Certified Nursing Assistant) after applying for PPE (Personal Protective Equipment) entered room of R59 with supplies for incontinence care in hand. V4 Removed blanket, raised the bed to the appropriate height, and removed the soiled diaper. V4 used perineal wipes to clean resident in the front of perineal area. Turned residents to the side. Changed gloves did not complete hand hygiene and used perineal wipes to clean buttock area. V4…

    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 before2026-03-27 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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

    Based on interview and record review the facility failed to have a process in place to ensure accuracy of a resident's personal blood glucose monitoring device and failed to accurately write parameters for a resident's blood pressure medication.This applies to 2 of 2 (R9 and R133) residents reviewed for quality care in the sample of 25.The findings include: 1.On 03/25/2026 at 2:05 PM, R133 stated he monitors his own glucose levels with his personal device and reports the result the nurse. R133 stated he has continuous glucose monitoring from a sensor attached to his skin that sends blood glucose levels to his personal cellular device. R133 stated he manages his device himself not facility staff. R133 stated the staff do not check his glucose levels with the facility device. On 03/25/2026 at 4:52 PM, V2 DON (Director of Nursing) stated R133 had not been assessed for using his personal glucose monitoring system. There is no physician order for R133 self-glucose monitoring. V2 DON stated the nursing staff should be utilizing the facility device to check and document R133's blood…

    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 before2026-03-27 · 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 properly maintain a venous access device.This applies to 1 of 1 residents R94 reviewed for venous access devices in a sample of 25.Findings include:On 03/24/2026 at 11:03 AM, R94 displayed his left upper arm where his single lumen PICC (Peripherally Inserted Central Catheter) had been inserted. The PICC line was covered by a transparent film dressing and had a dried brown substance underneath it at the insertion site. The transparent film dressing was bubbled not in contact with his skin at the insertion site. The dressing was dated 3/16/26. R94 did not know the day or date of when his PICC line dressing had been changed. R94 stated he was getting IV (Intravenous) antibiotics twice a day.On 03/25/2026 at 4:52 PM, V2 DON (Director of Nursing) stated PICC line dressings are changed every seven days and as needed. The RN (Registered Nurse) assigned to the resident is responsible for maintaining the PICC line dressing. The PICC line dressing should have been changed when the dried brown substance was noted. If 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-27 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to prevent a significant medication error.This applies to 1 of 1 residents R133 reviewed for significant medication errors in a sample of 25. Findings include:On 03/24/2026 at11:34 AM, R133 stated the prescriptions he was taking previously, he had not been receiving as they were ordered since admission to the facility. R133 stated the facility was provided with a list of the medications. R133 stated when he was at home his blood glucose was in a normal range. Since being in the facility his blood glucose readings have been too high.On 03/25/2026 at 4:35 PM, V22 QA (Quality Assurance) Pharmacist stated on 3/15/26 the pharmacy received an order for Metformin IR (Immediate Release) 500mg (Milligrams) twice daily. V22 stated the pharmacy assures there is no drug interaction for the list of medications submitted to them and they deliver the prescriptions. On 03/25/2026 at 4:09 PM, V23 Physician stated R133 was discharged from the hospital with orders. V23 stated he directed the nurse to continue and follow the hospital discharge…

    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 · D2025-04-28 · 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 timely incontinence care for residents that are dependent on staff assistance with activities of daily living (ADLs). This applies to three of seven residents (R1, R2, and R3) reviewed for incontinence care. The finding includes: R1, a [AGE] year-old, admitted on [DATE]. R1's diagnoses included diabetes mellitus, other disease of anus/rectum, ulcerative colitis, major depression, neuropathy, and fractures of the 4th and 5th thoracic vertebrae. The MDS (Minimum Data Set) dated March 16, 2025, indicates R1 is cognitively intact (BIMS (Brief Interview Mental Status) score of 15/15) and requires staff assistance with ADLs, including incontinence care. The care plan dated March 24, 2025, directs staff to provide incontinence care every two hours and as needed. R2, a [AGE] year-old, admitted on [DATE]. R2's diagnoses included right below-knee amputation, diabetes mellitus, peripheral vascular disease, gastroenteropathy. The MDS dated…

    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 · E2025-01-09 · tag F0755 — failed to provide safe pharmacy services — pattern
    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 record review the facility failed to ensure accurate and timely accounting of controlled medications and failed to ensure that blister packs containing controlled medications are maintained intact to ensure safe and effective use of the medications. This applies to 5 of 5 residents (R23, R49, R52, R81 and R103) reviewed for controlled medications in the sample of 27. The findings include: 1. On January 7, 2025 at 10:44 AM with V13 (Assistant Director of Nursing), the Restorative Hall medication cart shift change accountability record for controlled substances showed that the first shift on and off nurses' initials for January 7, 2025 were not documented by both the in-coming and out-going shift nurses to ensure that all controlled medications were accounted at the start of the shift. Inside the controlled medication compartment, multiple controlled medications were observed including: - R49's blister pack of Pregabalin 25 mg (milligram), dispensed by the pharmacy on January 2, 2025 originally containing 30 tablets. The said blister pack 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-09 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing 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 interview and record review, the facility failed to follow a physician's order to obtain a referral for a Corneal Specialist. This applies to 1 of 1 resident (R77) reviewed for vision services in the sample of 27. The findings include: The EMR (Electronic Medical Record) showed R77 was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's disease, chronic kidney disease, and type 2 diabetes. On January 6, 2025, at 10:20 AM, R77 said he has a hard time seeing and had a referral from the eye doctor but has not had an appointment made for him yet. On January 7, 2025, at 12:04 PM, V16 (Social Services) said she received an email from R77's POA (Power of Attorney) on December 19, 2024, requesting R77 have an appointment at a local eye clinic. V16 said she was out of the office until December 27, 2024, and on December 27, 2024, V16 notified V17 (R77's Nurse) to start the process to schedule the appointment for R77. V16 said she followed up with V17 today, and V17 had not started…

    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 · D2025-01-09 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide specialized mattress for a resident with worsening acquired pressure injury wound in accordance with wound care practitioner recommendation and their policy. This applies to 1 of 4 residents (R54) reviewed for pressure injury wounds in the sample of 27. The findings include: R54's medical record showed R54 admitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction, presence of malignant neoplasm of the breast, presence of cardiac pacemaker, osteoarthritis of the hip, and bilateral nuclear cataract and open angle glaucoma. R54's MDS (Minimum Date Set) dated October 10, 2024, showed R54 was moderately cognitively impaired, and required assistance with ADL (activities of daily living) care including set up assistance with eating and oral hygiene, partial assistance with upper body dressing, personal hygiene and rolling right and left in bed, and substantial…

    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
Show the remaining 14 citations
  • Potential for harm · D2025-01-09 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 that interventions were applied to provide comfort and prevent further worsening of resident's contracted hands. This applies to 2 of 3 residents (R17 and R41) reviewed for range of motion in the sample of 27. The findings include: 1). R17's face sheet showed her to be a [AGE] year old female admitted to the facility on [DATE] with diagnoses that include Congestive Heart Failure, Lack of coordination, Shortness of Breath, Chronic Kidney Disease, Major Depressive Disorder and Dementia. R17's Minimum Data Set (MDS) dated [DATE] showed R17 to be cognitively intact and that R17 required partial/moderate assistance for upper body dressing. R17's physician order dated September 26, 2024 showed the following: Apply rolled gauze to left hand contracture. On January 6, 2025 at 10:19 AM, R17 left hand was tightly closed and appeared contracted. R17 was not holding anything in her hand. On January 6, 2025 at 12:10 PM, R17 is lying in bed, her…

    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 · D2025-01-09 · tag F0806 — failed to honor food preferences — isolated
    Ensure 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

    Based on observation, interview and record review, the facility failed to provide a diet that includes the resident's diet preference. This applies to 1 of 1 resident (R137) reviewed for dining in the sample of 27. The findings include: R137's diagnoses on face sheet celiac disease, other seizures, difficulty in walking, not elsewhere classified, unspecified lack of coordination, acute respiratory failure, unspecified whether with hypoxia or hypercapnia. R137's admission MDS (minimum data set) dated December 12, 2024 included that R137 was cognitively intact. R137's diet order on Physician Order Summary included NAS (No Added Salt) diet, Regular texture, Thin liquids consistency, Gluten Free. R137's care plan revised on December 13, 2024 showed that R137 is at risk for alteration in nutritional status related to R137 is on a therapeutic diet. Interventions included to provide diet and supplements as ordered. On January 6, 2025, at 11:59 AM, R137 received room tray with chicken breast with no gravy, cooked carrots, a carton of 2% milk, 4 oz/ounce container of yogurt and a slice 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 · D2025-01-09 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    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 follow their policy for antibiotic stewardship to ensure residents received the appropriate antibiotic for an infection. This applies to 2 of 2 residents (R15 and R32) reviewed for antibiotic use in the sample of 27. The findings include: 1. The EMR showed R15 was admitted to the facility on [DATE], with multiple diagnoses including hypertensive heart and chronic kidney disease with heart failure, neuromuscular dysfunction of the bladder, and stage four pressure ulcer of the sacrum. On January 8, 2025, at 11:34 AM, V4 (Infection Preventionist Nurse) said R15 was started on ciprofloxacin (antibiotic) on October 23, 2024, for a urinary tract infection. V4 said R15's antibiotic timeout was completed on October 26, 2024. V4 continued to say when she completes the antibiotic timeout, V4 is checking to make sure a provider has seen the resident since the antibiotic was started and writes a progress note about the antibiotic. V4 said she does not review 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-15 · tag F0554 — pattern
    Allow residents to self-administer drugs if determined clinically appropriate.
    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 residents for self-administering medications and obtain physician orders to have medication stored in resident rooms. This applies to 4 out of 4 residents (R28, R32, R66 and R75) reviewed for self-administration of medications in a sample of 31. 1. R75's admission Records documents she was admitted to the facility on [DATE]. Diagnoses includes metabolic encephalopathy, multiple sclerosis, seizures, and chronic kidney disease with dependence on renal dialysis. On 3/12/2024 at 11:04 AM, R75 had a medication cup full of pills. R75 said around 9:30 AM, she told the nurse she was not feeling well and will take her medication later. R75 said the nurse left her medication on her bedside table so she can take it later. On 3/12/2024 at 11:22 AM, V13 (RN-Registered Nurse) said she attempted to administer R75's medications around 9:30 AM. She said the medications that were in the medication cup were Ascorbic Acid 500 mg (milligrams),…

    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 · Ecited before2024-03-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    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

    Based on observation, interview, and record review, the facility failed to secure a resident's oxygen cylinder. This applies to 5 of 5 residents (R2, R28, R32, R58, R110) reviewed for oxygen in a sample of 31. The findings include: On 3/14/24 at 11:30 AM, surveyor went to R28 and R58's room. R28 was lying in bed and R58 was being provided care by V18 (CNA-Certified Nursing Assistant). In between their bed and behind R28's wheelchair, there was a medium size oxygen cylinder on the floor that was unsecured. R28 was unsure of how long the oxygen cylinder was unsecured on the floor. When surveyor brought it to V18's attention, V18 stated, I didn't put it there. The oxygen tank should always be in a carrier. That's a big no no. I will find out who did that and I will try to find the carrier for that oxygen tank. I will take care of it now. On 3/14/24 at 11:35 AM, V17 (RN-Registered Nurse) stated, The portable oxygen tank should be in a carrier or bag behind the wheelchair. It should be secured when it's on the floor. It will most definitely combust if it falls and it will hurt 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-15 · tag F0813 — pattern
    Have a policy regarding use and storage of foods brought to residents by family and other visitors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview & record review, the facility failed to place a thermometer in resident refrigerators, complete temperature logs, remove undated and expired items and keep refrigerators clean. This applies to 5 of 5 residents (R28, R32, R85, R90 and R110) in a sample of 31. Findings include: 1. On 3/12/24 at 11:55 AM R90's refrigerator had no thermometer in it and no temperature log on the outside of the refrigerator. Refrigerator was 'dirty' with dried up juice on the floor of the refrigerator. V16 (CNA-Certified Nursing Assistant) witnessed these observations and agreed that there is no temperature log on the refrigerator and no thermometer inside. The refrigerator contained following food with no date: 1. Sandwich in ziplock bag - No date 2. Cups (2) with cucumber salad dated 3/7/24 3. Steirofoam box with rice - no date 4. Stierofoam box with pureed beans - no date 5. Ziplock bag with cheese - no date On 3/13/24 at 2:00 PM, R90's refrigerator had no thermometer in it and no temperature log on the outside of the refrigerator. Refrigerator was 'dirty' with dried up…

    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 · D2024-03-15 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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 follow its advance directives policy. This applies to 2 of 10 (R40 & R14) reviewed for advance directives in a sample of 31. Findings include: 1. On 3/12/2024 at 2:56 PM, R40's EMR (Electronic Medical Record) review was completed and did not show an order indicating his advance directives. R40's EMR showed he was admitted to the facility on [DATE] and was receiving hospice services. R40 had an advance directive form dated 1/27/2021 indicating he was a DNR (Do Not Resuscitate) with selective medical treatment interventions. R40's Order Summary Report dated 3/14/2024 showed a physician order indicating DNR code status was entered on 3/12/2024 (during the survey). 2. On 3/12/2024 at 1:53 PM, R14's EMR review was completed and did not show an order indicating his advanced directives. R14's EMR showed he was admitted to the facility on [DATE]. R14's EMR did not show an advance directive form. R14's Order Summary Report dated 3/13/2024 showed a physician…

    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 · D2024-03-15 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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 R24 was free from physical restraint. This applies to 1 of 1 resident (R24) reviewed for physical restraints in a sample of 31. Findings include: The EMR (Electronic Medical Record) showed R24 was admitted to the facility on [DATE], with multiple diagnoses including multiple sclerosis, paraplegia, and functional quadriplegia. R24's MDS (Minimum Data Set) dated 1/01/2024 showed R24 required substantial to maximal assistance from staff for upper body dressing. On 3/12/2024 at 12:29 PM, R24 was sitting in her high-back wheelchair in the dining room with a seatbelt around her waist. On 3/14/2024 at 11:11 AM, V7 (Certified Nurse Assistant/CNA) and V8 (CNA) assisted R24 into her high-back wheelchair. V8 applied a push-button seatbelt around R24's waist area. R24 tried several times to release the seatbelt but was not able to, R24 said she could not do it because it was too hard. V8 said R24 sometimes could not release her seatbelt. 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-15 · tag F0660 — isolated
    Plan the resident's discharge to meet the resident's goals and needs.
    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 assist with discharge planning. This applies to 2 of 3 residents (R106 and R14) reviewed for discharges in a sample of 31. Findings include: 1. The EMR (Electronic Medical Record) showed R106 was admitted to the facility on [DATE], with diagnoses of chronic obstructive pulmonary disease, alcohol abuse, and carotid artery stenosis. R106's MDS (Minimum Data Set) dated 12/07/2023 showed R106 was cognitively intact. The MDS continued to show R106 did not require the use of a mobility device and required setup or clean-up assistance with his personal hygiene care. On 3/12/2024 at 10:50 AM, R106 said he liked the facility, but he wanted to be discharged back to the community. R106 said he was independent with his care. R106 said he could not recall if facility staff had spoken to him about his discharge goals. 2. The EMR (Electronic Medical Record) showed R14 was admitted to the facility on [DATE], with multiple diagnoses including cellulitis to lower limbs…

    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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-15 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    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 utilize communication tools for the use of residents and staff. The facility failed to provide written information in the residents preferred language. This applies to 3 of 3 residents (R21, R104 and R114) reviewed for communication in a sample size of 31. Findings include: 1. R114 was admitted to the facility on [DATE]. R114's MDS (Minimum Data Set) dated 1/27/24 shows she is cognitively intact with BIMS (Brief interview for Mental Status) score of 13. On 3/12/24 at 1:15 PM, V19 and V20 Family Members were visiting R114 in her room. V20 had to assist V19 in spelling her name for the surveyor. V20 stated R114 speaks and reads in Spanish only. V20 stated he and V19 speak some English but V19 reads only Spanish. V20 stated he does not read well in English. Both V19 and V20 stated they preferred to receive written information in Spanish. V20 stated R114 would be discharged home with V19 her primary family caregiver. On 3/14/24 at 8:49 AM, V4 RN…

    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 before2024-03-15 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 interview and record review, the facility failed to monitor lab value medications for cardiac/anti-rhythmic (high risk) medications. This applies to 1 of 1 resident (R43) reviewed for high risk medications in a sample of 31. The findings include: R43 was admitted to the facility on [DATE]. R43's EMR (Electronic Medical Record) shows the following diagnoses of hypertensive heart and chronic kidney disease with heart failure and stage 1 though stage 4 chronic kidney disease or unspecified chronic kidney disease, chronic combined systolic (congestive) and diastolic (congestive) heart failure, heart failure, heart disease and atherosclerotic heart disease heart disease of native coronary artery without angina pectoris. R43's Physician Order Sheet (POS) shows the order for Digox Oral Tablet 125mcg (Digoxin) give 1 tab by mouth every 72 hours for CAD (coronary artery disease). R43's care plan (initiated 5/31/18) shows that R43 is using digoxin related to Congestive Heart Failure (CHF)/atrial flutter with…

    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 before2024-03-15 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to change a loose and soiled midline dressing. This applies to 1 out of 2 residents (R17) reviewed for peripheral lines in a sample of 31. Findings include: R17's admission Records documents he was initially admitted on [DATE]. R17 was re-admitted to facility on 2/6/2024. R17's EMR (Electronic Medical Record) documents diagnosis of osteomyelitis of vertebra, sacral and sacrococcygeal region. R17's March 2024 POS (Physician Order Sheet) documents an order for Ceftriaxone 2 grams every 24 hours via midline for nine days. R17's Progress Notes on 3/7/2024 documents a midline catheter was inserted on his right upper arm for antibiotic infusion. Separate observations on 3/12/2024 at 11:02 AM, 3/13/2024 at 9:45 AM and 3/13/2024 at 10:30 AM showed R17 had a transparent dressing dated 3/7/2024. Both right and left side of the dressing was loose and not adhering to R17's skin. Blood was noted on the gauze under the clear dressing. On 3/13/2024 at 9:45…

    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 · D2024-03-15 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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 appropriately contain respiratory equipment. This applies to 3 of 3 residents (R20, R37, R85) reviewed for oxygen in a sample of 31. The findings include: 1. On 3/12/24 at 11:32 AM, R20 was lying in bed. Behind her was an end table with her CPAP (Continuous Positive Airway Pressure) machine, tubing and face mask. The tubing and face mask were not in a bag. R20 stated she was not sure if her tubing was ever changed. R20's face sheet shows diagnoses that include chronic respiratory failure with hypoxia and obstructive sleep apnea. R20's POS (Physician Order Sheet) shows an order of CPAP 5-20 CM (Centimeters) water with heated humidity with full face mask, on at night and off in AM. 2. On 3/12/24 at 11:50 AM, surveyor went to R85's room. She was not present. R85's BPAP (Bilevel Positive Airway Pressure) machine was on an end table next to her bed. The tubing and face mask were not in a bag. R85's nasal cannula and tubing that was under her…

    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 before2023-08-16 · 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 observation, interview and record review, facility failed to implement care planned fall interventions. This applies to 1 of 4 residents (R7) reviewed for falls in a sample of 10. Findings include: 1. R7's admission Record dated 8/9/2023 documents R7 admitted to the facility on [DATE] with diagnoses to include compression fracture of the Thoracic 7-8 vertebra and multiple rib fractures. R7's Care Plan dated 6/28/2023 documents R7 at high risk for falls with interventions to include to keep his bed in the lowest position. R7's Fall Incident Report dated 6/29/2023 at 4:55 AM documents R7 found on the floor without the call light activated, reporting to staff he attempted to stand up and fell; he denied striking his head. On 8/15/2023 at 2:07 PM, V9 (Nursing Assistant) stated at the time she discovered R7 on the floor on 6/29/2023 he was next to his bed and his bed was approximately 2 feet from ground, indicating with her hands the approximate level of the bed at her hip level. On 8/16/2023 at 9:05 AM V2…

    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

“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 3 of 52.5+0.5 vs chain
Quality measures 3 of 53.3-0.3 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 SNF50%since 01/01/2017
GPN FAMILY TRUST U/A/D 4/28/08Organization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF50%since 01/01/2017
LAKE FOREST BANK & TRUST COMPANY, N.A.Organization5% OR GREATER SECURITY INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 12/01/2024
PRAIRIE PROPERTY HOLDINGS, CCOrganization5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 02/01/2014
SHABAT, MENACHEMIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2017
LEGACY HEALTHCARE FINANCIAL SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2014
KALRA, SANDEEPIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2014
LANNING, CAMBERLYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2015
RSM US LLPOrganizationADP OF THE SNFsince 01/01/2024

CMS files one row per role, so the 18 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.

6 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.

$13.7M
Net patient revenuemost recent cost report
-14.0%
Operating marginrevenue minus expenses
$1.8M
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 20%Medicare 5%Other / private 75%

This home reported $1.8M paid to related parties — landlords or management companies under common ownership — equal to about 12% 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

$352per resident / day
operating cost
$10,710per month
≈ monthly operating cost
$309per 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 145006. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-27, 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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