Jennings Terrace
275 South Lasalle, Aurora, IL 60505 · Non profit - Corporation · 60 certified beds · (630) 897-6947 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- 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
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 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 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 29.0% | 13.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 7.4% | 6.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.2% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.6% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.7% | 54.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.7% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 29.6% | 14.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 23.8% | 18.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 97.9% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.8% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 16.6% | 20.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 17.3% | 21.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.2% | 1.4% | better |
| Short-stay residents rehospitalized after admission | 30.5% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 20.3% | 13.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 4.80 | 2.02 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.46 | 2.22 | 1.80 | worse |
‡ 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.
Therapy staffing: this home’s payroll records show 0.21 therapist hours per resident per day in 2026Q1 — more than 25% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 16% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 60 beds and averages 45.8 residents a day — about 76% occupied, or roughly 14 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 2.95 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.73 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.86 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 2.72 hrs/resident/day on weekends vs 3.05 on weekdays — 11% thinner on weekends. RN hours go from 0.77 to 0.66 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
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.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.
- Potential for harm · D2025-01-28 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
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 respond to a resident's (R1) family representative billing concern. This applies to 1 of 3 residents (R1) reviewed for grievances. The findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE] and discharged on 2/18/2024. On 1/28/2025 at 11:35 AM, V5 (R1's Family Member) said that on 9/20/2024 he contacted the facility after reviewing R1's billing for the months of April through June 2023 (from over a year earlier) when R1's family was paying out of pocket after R1 was approved for public aid. V5 said he notified V1 (Administrator) and V2 (Business of Manger/BOM) of his billing grievance regarding R1's credit due. V5 said he felt the facility was not responding promptly to his grievance. V5 said he then contacted V3 (Ombudsman) to help him find a resolution with the facility. On 1/28/2025 at 11:00 AM, V3 (Ombudsman) said she contacted V1 and V2 on 12/13/2024 to assist V5 with his grievance but was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-11-21 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure the facility had an assessment performed that identifies where Legionella and other opportunistic waterborne pathogens could grow. This applies to all 46 residents that reside in the facility. The findings include: The facility's Long Term care facility application for Medicare and Medicaid (CMS (Centers for Medicare & Medicaid Services)-671 form) dated November 18, 2024 showed that there were 46 residents residing at the facility. On November 20, 2024 at 11:12 AM, V6 (Maintenance Director) stated the facility does not have an assessment for Legionella or other opportunistic water borne pathogens. V6 stated he is not aware of any Legionella assessment being done in the last 3 years that he has been working at the facility. V6 stated, they will be using a specific company to do the facility's assessment for Legionella and other waterborne pathogens. V6 stated that they have not utilized the company yet. V6 stated the facility does not have an assessment that shows where specifically Legionella or other waterborne…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-11-21 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 label and date medications once opened to determine the expiration date. The facility failed to remove expired medications, and remove or dispose narcotic medications that were in a broken sealed container. In addition, the facility failed to store suppository medications in a sanitary manner. This applies to 8 residents (R3, R8, R16, R19, R29, R30, R40, R41) reviewed for medication storage and labeling in the sample of 12. The findings include: On November 18, 2024, from 3:27 PM through 3:58 PM, observation of medication carts and medication rooms' refrigerator were conducted with V15 and V16 (Both Nurses). 1. R40's Latanoprost 0.005% (ophthalmic solution) label showed that it was opened on September 20, 2024, and expired on November 1, 2024. 2. R19's Latanoprost .005% (ophthalmic solution) label showed that it was opened on September 22, 2024, and expired on November 3, 2024. 3. R8's Latanoprost 0.005% (ophthalmic solution) opened on July 8, 2024. Pharmacy recommendation showed to discard 6 weeks after it…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-11-21 · tag F0805 — failed to prepare food in a form residents can eat — patternEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
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 prepare the green peas to pureed consistency for residents on pureed diets. This applies to 5 of 5 residents (R3, R6, R13, R17, R23) reviewed for pureed diet in the sample of 12. The findings include: On November 19, 2024 at 10:30 AM, the pureed green peas preparation done by V5 (cook) was observed in the facility kitchen. V5 stated that she was preparing for five residents who are on pureed diets. According to V5, the green peas were frozen, and she had cooked it. V5 placed eight scoops of 4 ounces (total of 32 ounces) green peas inside the food processor, added 4 ounces of butter and pureed the mixture for about three minutes. V5 then opened the food processor and transferred the processed green peas inside a small metal pan. According to V5, she was done processing the green peas and she will place the small metal pan inside the warmer because the processed green peas was ready to be served to the residents on pureed diet. V5 was asked why she did not test the processed green peas to make sure it was 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.
- Potential for harm · E2024-11-21 · tag F0881 — failed to use antibiotics responsibly — patternImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based interview and record review the facility failed to utilize the McGeer Criteria from March 2024 through November 19, 2024 for residents with suspected infections based on their policy. This applies to 9 of 9 residents (R1, R5, R6, R7, R11, R12, R20, R37, R46) reviewed for antibiotic stewardship in the sample of 12. The findings include: On November 20, 2024 at 11:38 AM, V3 (Infection Preventionist/Assistant Director of Nursing) stated that the facility is using the McGeer Criteria to ensure residents are not prescribed unnecessary antibiotics. V3 stated that in March of 2024, she stopped utilizing the McGeer Criteria. Surveyor reviewed the facility's infection tracking binder and there were McGeer Criteria filled out for residents in January and February of 2024, but there were no McGeer Criteria for residents for the remainder of the year (from March 2024 to present). V3 stated there was no McGeer Criteria documentation stating whether residents who were prescribed antibiotics from March 2024 to present, either met or did not meet standards for antibiotic utilization. V3…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-11-21 · tag F0947 — failed to train nurse aides adequately — patternEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to provide dementia training for the CNAs (Certified Nurse Assistants) working in the facility and who were required to care for residents with dementia. This applies to 26 of 26 residents (R1, R3, R4, R6, R8, R11, R12, R14, R15, R16, R19, R20, R21, R23, R24, R26, R27, R28, R33, R36, R38, R40, R42, R44, R45 and R46) identified by the facility as having a diagnosis of dementia. The findings include: On November 20, 2024, at 10:03 AM, V9 (CNA (Certified Nursing Assistant) Supervisor) said that as the CNA Supervisor she does the CNAs annual evaluations and does the in-services for the CNAs. V9 said when needed, she will do re-education along with return demonstration on skills provided to the residents. V9 said she does not do dementia training and cannot remember having attended a training on dementia. V9 said V8 (Community Relations Coordinator) does dementia, resident rights, abuse and neglect trainings. The facility trainings are all done as in-services and the documentation is the sign in sheet. On November 20, 2024, at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-21 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review, the facility failed to assess a resident's wound during a course of treatment and document the status of the wound weekly and revise the care plan interventions for wound care. This applies to 1 of 2 residents (R5) reviewed wound care in the sample of 12. The findings include: R5's electronic medical record showed a [AGE] year old female admitted to the facility on [DATE] with diagnoses that include Osteoarthritis, Congestive Heart Failure, Obesity, Difficulty Walking, Weakness, Cognitive communication deficit, Type 2 Diabetes, and Diarrhea. R5's annual Minimum Data Sheet dated August 12, 2024 showed her to be cognitively intact. On November 18, 2024 11:23 AM, R5 was observed to be alert and oriented and stated that the facility took her air mattress and she has buttocks pain. Later, on November 19, 2024 1:40 PM, R5 stated her bottom hurts and she has an open wound on her bottom. R5 stated it has been there for a couple months. V19 (Wound Care Doctor) note 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.
- Potential for harm · Dcited before2024-05-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to safely transfer a resident using a wheelchair. This applies to 1 of 4 residents (R1) reviewed for accident hazards in the sample of 4. The findings include: On 5/18/24 at 9:20 AM, R1 stated, she was being transported from her room to the DR (dining room) on 5/13/24 by V3 (Activity Aide) in her wheelchair, to go for Bingo. R1 stated, she felt her wheelchair was not moving smoothly and she toppled over and fell to the ground. R1 stated, she hit her head and it was bleeding. There was a pair of foot pedals for wheelchair in the room. R1 stated, the foot-pedals are never put on her wheelchair. R1 stated, she usually propels herself and sometimes, the staff helps her. On 5/18/24 at 11:45 AM, V6 (Maintenance Director) stated, he saw R1's foot caught in the front wheel of the wheelchair and then R1 tipped forward and fell to the floor. V6 stated, after R1's fall, he checked the wheelchair and there was nothing wrong with the wheels or the break…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-01-19 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the sanitization of the kitchen, and discard and store food items to prevent the transmission of food borne illness. This applies to all residents that reside in the facility. Findings include: The facility's 1/16/2024 CMS-671 Form showed 50 residents live in the facility. 1. On 01/16/24 at 11:23 AM, quality assurance checks of red sanitization buckets and the three-compartment sink was conducted with V6 Dietary Manager. Sanitizing Bucket #1 strip tested at zero ppm (parts per million). Sanitizing Bucket #2 was dumped and refilled by V8 Dietary Aid before V6 tested sanitizer concentration. Bucket #2 with sanitizer strip tested at zero ppm. Sanitizing Bucket #3 strip tested at zero ppm. The three-compartment sanitizing sink tested at zero ppm. V6 Dietary manager stated staff should be changing the sanitization bucket several times during meal preparation and the person that changes should be checking it. Staff have not been checking the sanitization bucket or documenting it- ultimately, it's my…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-01-19 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake 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
Based on observation, interview and record review, the facility failed to ensure lint was removed from the facility's dryers, posing a fire hazard. This applies to all residents residing in the facility, and all staff and the public that come to the facility. The findings include: On 01/17/24 at 3:48 PM, the facility's three dryers had lint in the bottom of the dryers. In dryer 1, there was approximately a one inch layer of lint on the bottom and on all 4 sides of the lint basket. Dryer 1 was empty. In dryers 2 & 3, there was lint approximately 1 inch thick on the top of the lint screens and there was a pile under both the screens that were about 10 inches high and about 10 inches wide. Both of these dryers were with clothes in them. On 1/17/24 at 3:51 pm, V16 (Laundry staff) said that she cleans the dryers once a day at the end of her day, and she will be cleaning the lint out of these dryers at the end of this day. V16 said that she does about 20 to 30 loads a day. V16 said she does not keep a log when she cleans the lint from the machines. V12 (Maintenance Director) said that if…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 12 citations
- Potential for harm · D2024-01-19 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond 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 respond to a potential abuse allegation by not thoroughly investigating and not reporting the allegation to the State Survey Agency. This applies to 1 of 1 (R9) reviewed for abuse in the sample of 27. The findings include: The EMR (Electronic Medical Record) showed R9 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease, anxiety, delusional disorder, hallucinations, schizoaffective disorder, and dementia. R9's MDS (Minimum Data Sheet) dated 11/02/2023 showed she had short and long-term memory problems and required the use of a manual wheelchair with partial to moderate staff assistance. The EMR showed R31 was admitted to the facility on [DATE], with multiple diagnoses including parkinsonism, anxiety, amd depression. R31's MDS dated [DATE] showed she was cognitively intact. On 1/17/2024 at 10:33 AM, R31 was participating in the facility's resident council group meeting and shared a concern from two months ago…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-19 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure residents receive assistance for grooming and hygeine cares. This applies to 1 of 3 residents (R30) reviewed for grooming needs. The findings include: On 1/16/24 at 11:08 AM, R30 was sitting in the wheelchair in her room. R30 had several white hairs on her upper lip and chin. R30 said she does not like the hair on her chin and upper lip and would like it off. R30 said someone was supposed to do it, but they never did. On 1/17/23 at 8:46 AM, hair was still noted on her upper lip and chin. R30's MDS (Minimum Data Se) dated 11/3/23 shows that R30's cognition is moderately impaired and R30 needs moderate assistance with personal hygiene. R30's current care plan shows that R30 is at risk for ADL self-care performance deficit and needs extensive assist of 1 staff participation with personal hygiene. On 1/18/24 at 3:38 PM, V3 (ADON/Assistant Director of Nursing) said CNAs (Certified Nurse Aides) were responsible for assisting residents with ADL care. V3 said R30 does not have a history of refusing care, she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to secure hazardous chemicals. This applies to 4 of 10 residents (R2, R43, R4, R10) reviewed for safe environment. Findings include: 1. On 01/16/24 at 10:54 AM, one 32 oz spray bottle of bleach was found in R2 and R43's shared bathroom. R43's 11/6/23 MDS (Minimum Data Set) showed that his mental status is severely impaired. R2's EHR (Electronic Health Record) showed diagnoses including dementia, schizoaffective disorder bipolar type, neurocognitive disorder, and major depressive disorder. On 01/16/24 at 11:14 AM, V11 (Housekeeping staff) said she had cleaned R2 & R43's shared bathroom and left the bottle of bleach in there. 2. On 01/16/24 at 11:02 AM, a 32 oz. spray bottle of odor eliminator was found in R4 and R10's shared bathroom. R10's EHR showed diagnoses including schizoaffective disorder, major depressive disorder, and far sightedness. R4's EHR showed diagnosis including dementia with agitation, mild cognitive impairment and age-related cognitive decline. On 01/16/24 at 11:19 AM, V11 was shone the bottle…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure sanitary storage/containment of respiratory equipment when not in use. This applies to 1 of 2 residents (R49) reviewed for respiratory equipment in a sample of 27. The findings include: On 1/16/24 at 11:19 AM, R49's oxygen tubing and nasal cannula were observed on the floor. On 1/17/24 at 11:02 AM, R49 was sitting in his wheelchair receiving nebulizer treatment. R49's oxygen tubing and nasal cannula were again on the floor. R49 said he uses the oxygen. R49's EMR (Electronic Medical Records) shows R49's diagnosis which includes Chronic Obstructive Pulmonary Disease (COPD). R49's January 2024 Physician Order Sheet showed that R49 had an order to administer oxygen 2-4 liters via nasal cannula as needed maintain oxygen over 92% every shift related to COPD. On 1/17/24 at 3:44 PM, V3 (ADON/Assistant Director of Nursing) said if oxygen is not in use, the oxygen tubing and nasal cannula should be contained in a bag and not on the floor for infection control reasons. The facility's Oxygen Tubing Storage 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.
- Potential for harm · D2024-01-19 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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 correct dose of insulin medication. This applies to 1 of 3 residents (R39) reviewed for insulin medication administration in a sample of 27. The findings include: On 1/17/24 at 8:13 AM during medication pass, V7 (Agency RN/Registered Nurse) went to R39's room and to administer the scheduled dose of insulin. V7 said that R39 has an order to receive 50 units of Lantus (insulin). V7 administered the dose of insulin to R39's right upper arm. When V7 was done administering the insulin, some insulin remained in the insulin pen. Surveyor asked V7 for the insulin pen; there were still 2 units of insulin left in the pen and the pen's dial was at 2 with R39 not receiving the full prescribed dose. V7 said that dial should be at 0. R39's EMR (Electronic Medical Records) shows diagnoses which includes Type 2 Diabetes Mellitus with unspecified diabetic retinopathy and macular edema, and Type 2 diabetes mellitus with diabetic neuropathy. R39's POS (Physician Order Sheet) shows the following order for Insulin…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-19 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 isolate a covid-positive resident from her covid-negative roommate. This applies to 1 of 5 residents (R24) reviewed for infection control. Findings include On 01/17/24 at 10:29 AM, V2 DON (Director of Nursing) stated there was one resident in the facility positive for covid (R45) and one resident under observation for covid (R24). V2 stated that both residents were in the same room. V2 stated they were instructed by the physician to keep the residents together in the same room On 01/17/24 at 11:10 AM, V2 DON stated the facility policy follows the department of health guidelines to isolate covid positive residents. If there is a roommate, they should be relocated if they have tested negative for covid. V2 stated in her professional opinion, the two residents should have been separated. On 01/18/24 at 4:30 PM, V3 ADON stated residents can share a room if they have the same infection and if residents don't have the same infection, they should be separated. V3 stated that on 1/11/24 and 1/15/24 the facility had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-19 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure a resident had a functional call light available. This applies to 1 resident (R36) reviewed for call lights. The findings include: On 01/16/23 at 12:54 pm, a male voice was heard calling out of R36's room. The voice was yelling, get me out of here. At 12:59 pm, R36 was seen in his room yelling Get me out of here. At 1:02 PM, R36 was in his room and continued to yell, Can I get out of here? R36 was asked if he had turned his call light on and he said no one is answering it. R36's call light was not activated. At 1:12 pm, R36 was seen in his room still yelling for help and still no staff came to R36's aid. At 1:23 pm, R36 asked the surveyor if they would help him get out of bed because it was too warm in his room. R36 pushed his call light button to turn on his call light and the call light did not turn on. At 1:28 pm, V9 (CNA) Certified Nursing Assistant was asked by the surveyor to come into R36's room and test his call light. The call light only came on after he re-plugged in the call light, but then…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-10-21 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have call light within access to dependent residents. This affects 4 of 4 residents (R2, R35, R147, and R246) reviewed for call light accessibility and ADL (Activities of Daily Living) care in a sample of 19 Findings include: 1. R35 is an [AGE] year-old male with moderate cognitive impairment as per Minimum Data Set (MDS) dated [DATE]. R35 requires two-person extensive physical assistance for bed mobility/transfer/toilet use/personal hygiene/dressing as per MDS data. On 10/18/22 at 10:19 AM, R35 was observed in his bed with a call light, not within reach. The call light was observed hanging from the wall behind the headboard of the bed. Record review on R35's ADL care plan document: Ensure that my call light and frequently used items is within close reach when I am in the room. Remind me to call and to wait for assistance when needed. 2. R2 is a [AGE] year-old male with moderate cognitive impairment as per MDS dated [DATE]. R2 requires…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-10-21 · tag F0692 — failed to prevent malnutrition and dehydration — patternProvide 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 ensure residents received nutritional supplements or an alternative supplement as ordered by the Physician and recommended by the facility's registered dietitian to prevent weight loss. This applies to 4 of 12 residents (R21, R33, R34, R149) reviewed for nutrition with the nutritional supplements in a sample of 19. The Findings include: 1. R21 was admitted to the facility on [DATE] with diagnoses including diabetes, dysphagia, gastroesophageal reflux disease, and dementia. R21's Quarterly Minimum Data Set (MDS) dated [DATE] showed that R21 is severely cognitively impaired and requires extensive assistance with eating. R21's admission weight on 04/08/2022 is noted to be 151 pounds and 153 pounds on 08/01/2022. R21's last weight was noted to be 143 pounds on 09/03/2022. On 10/18/2022 at 1:17PM, R21 was sitting in the dining room, and V 9(R21'S POA-Power of Attorney) was assisting R21 in eating lunch. R21 appeared thin/emaciated, 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.
- Potential for harm · Ecited before2022-10-21 · tag F0761 — failed to label and store drugs safely — patternEnsure 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, failed to properly secure resident medications and failed to remove over the counter medications from resident's rooms. This applies to 4 of 4 residents (R22, R23, R25 and R195) reviewed for medications in a sample of 19. Findings include: 1. On 10/18/22 at 10:32 AM during the initial tour, there bottle of Afrin nasal spray and Robitussin nighttime maximum strength cough syrup on R195's bedside table. R195 said she brought both medications from home, and she uses the nasal spray for sinus congestion. R195's current electronic POS (Physician Order Sheet) was reviewed; there was no order for both medications, and R195 did not have an order for any medications to be at the bedside. 2. On 10/18/22 at 11:03 AM, there was tube of Bengay ultra strength topical analgesic cream on R22's bed. At 11:12 AM, R22 said he uses the Bengay for his knee pain but has not used it in a while. On 10/20/22 at 9:33 AM, V2 DON (Director of Nursing) said R22's daughter brought in the Bengay and R22 does not have an order for it to be at the bedside. R22'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.
- Potential for harm · E2022-10-21 · tag F0809 — failed to serve meals on a reasonable schedule — patternEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide bedtime snack to residents. This applies to 9/9 residents (R9, R12, R13, R22, R30, R35, R40, R43, and R44) reviewed for meal frequency and bedtime snacks in a sample of 19. Findings include: On 10/18/2022 at 11:03 AM R30 stated she has not been offered bedtime snack in two months. R30 stated she gets hungry around 2 AM. R30 stated that she did not know she can ask for snacks after dinner. On 10/20/2022 at 11:41 AM, V4 (Dietary Manager) provided untitled policy and procedure stating HS (7 PM) snacks must be put at each nurse's station (North and South) in Nursing Center by the 10 AM aide before the PM [NAME] leaves at night. On 10/20/22 at 12:07 PM, interview with DON stated that all residents are offered bedtime snacks every night. On 9/28/22 at 10:30 AM, during the resident groups, the group members (R9, R12, R13, R22, R35, R40, R43, and R44) unanimously stated, We are not getting any bedtime snack. They are not offering any bedtime snack. Sometimes we are hungry at 3:00 AM, so we should get some snack at bedtime.…
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.
- No harm found · C2024-11-21 · tag F0847 — widespreadInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility's Arbitration Agreement failed to have the required language in the Arbitration Agreement Contract. This applies to all 46 residents residing at the facility. The findings include: The facility's Long Term care facility application for Medicare and Medicaid (CMS (Centers for Medicare & Medicaid Services)-671 form) dated November 18, 2024 showed that there were 46 residents residing at the facility. On November 20, 2024, at 2:02 PM, V8 (Community Relations Coordinator) said when there is a new admission, she sit downs and goes paragraph by paragraph through the contract with the resident and/or their representative. There have been situations where V8 said she has gone over the contract paragraph by paragraph over the phone with a resident's representative who was not able to come into the facility. On November 20, 2024, at 12:18 PM, facility provided their undated admission packet titled, Contract Between Resident and [facility name] which included the arbitration agreement. Under Section X. Miscellaneous Provisions N.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| SILVER, JOMARIE | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 04/28/2022 |
| AKERS, LYNN | Individual | CORPORATE DIRECTOR | since 10/28/2020 |
| BIERITZ, JONATHAN | Individual | CORPORATE DIRECTOR | since 07/20/2022 |
| BROWN, JIM | Individual | CORPORATE DIRECTOR | since 10/28/2020 |
| KLECKNER, DUANNE | Individual | CORPORATE DIRECTOR | since 10/28/2020 |
| UNDERWOOD, DAVID | Individual | CORPORATE OFFICER | since 10/28/2020 |
CMS files one row per role, so the 8 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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.
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 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 146197. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-21, 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.