La Bella of Aurora

Location & what’s nearby

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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

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.

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.

31.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 35 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.12 therapist hours per resident per day in 2026Q1 — more than 8% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% 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.

Staffing

How full it usually is: this home is certified for 68 beds and averages 60.8 residents a day — about 89% occupied, or roughly 7 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.93 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.49 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.83 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 2.55 hrs/resident/day on weekends vs 3.09 on weekdays — 18% thinner on weekends. RN hours go from 0.52 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

36 citations, most serious first. The 15 most serious are shown; the remaining 21 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-07-17 · 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 ensure dressing changes were done as ordered (R1), and failed to ensure weekly wound assessments and documentation of the assessments were completed, for 2 of 5 residents (R1, R4) reviewed for non-pressure wound care in the sample of 6.This failure resulted in R1's wound getting a maggot infestation, and the wound dehiscing and getting infected. R1 was sent out to a local emergency room, diagnosed with osteomyelitis, requiring two intravenous (IV) antibiotics to prevent sepsis, surgical intervention, and critical care hospital admission. This failure resulted in an Immediate Jeopardy.The Immediate jeopardy began on 7/3/2025 when the facility failed to do the dressing change as ordered and failed to assess R1's surgical site and document an assessment. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 7/16/2025 at 12:16 PM. The surveyor confirmed by observation, record review, and interview, that the Immediate Jeopardy was removed on 7/17/2025, but noncompliance remains at Level Two,…

  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
• Immediate jeopardy · J2025-04-23 · tag F0678 — failed to provide CPR when needed — isolated
  Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
  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 record review and interview the facility failed to perform CPR (Cardio-Pulmonary Resuscitation) correctly as per standards of practice, failed to call a code blue within the facility, and failed to call EMS system (911) for an unresponsive resident identified as a full code on the physician's orders in accordance with the Facility policy. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on [DATE], at 5:25 AM, when R55, who had full code orders, expired in the facility after being found unresponsive and staff did not perform CPR as per the Standards of Practice and did not follow their policy for Medical Emergencies. V1 (Administrator) and V24 (Regional Director of Operations) were informed of the Immediate Jeopardy on [DATE], at 4:17 PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on [DATE], but the facility remains out of compliance at a severity level two because additional time is needed to evaluate the implementation and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2026-03-12 · tag F0602 — failed to protect residents from theft of their belongings — isolated
  Protect each resident from the wrongful use of the resident's belongings or money.
  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 prevent diversion of resident's money by a staff member.This applies to 1 of 3 residents (R3) reviewed for misappropriation of funds in the sample of 11.This failure resulted in psychosocial harm when R3 stated she feels terrible and bothered when the staff member took her hard-earned money without her consent. The findings include:R3 was admitted to the facility on [DATE]. R3 had multiple diagnoses including metabolic encephalopathy, type 2 diabetes mellitus without complications, generalized muscle weakness, unspecified lack of coordination, and anxiety disorder, based on the face sheet.R3's quarterly MDS (Minimum Data Set), dated February 6, 2026, showed the resident was cognitively intact.On March 6, 2026, at 2:04 PM, R3 was sitting on her bed inside her room. R3 was alert and was able to answer questions. R3 stated she had a car accident sometime in July 2025 and since admission at the facility, there were several suspicious transactions in 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-07-17 · tag F0628 — isolated
  Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to document a resident's discharge correctly for 1 of 3 residents (R2) reviewed for discharge. This failure resulted in R2 losing his Medicare coverage from [DATE]-[DATE], having to cancel important diagnostic testing and a follow-up appointment with his neurosurgeon, not having CPAP (continuous positive airway pressure) supplies due to lack of medical coverage, and having to spend many hours and days trying to get his Medicare coverage reinstated.The findings include:R2's admission Record, printed by the facility on [DATE], showed he had diagnoses including, but not limited to partial intestinal obstruction, type II diabetes mellitus with hyperglycemia, gastrointestinal hemorrhage, anemia, acute kidney failure, neoplasm of unspecified behavior of bone, soft tissue, and skin, long-term use of non-insulin antidiabetic drugs, hypertension, anuria, and oliguria (reduced urine output or complete absence of urine output). The admission Record showed R2 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-04-28 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to monitor and ensure a resident on a gastrostomy tube feeding was receiving the total amount ordered. This failure resulted in a 10.44 percent weight loss in three months. This applies to 1 of 2 residents (R36) reviewed for gastrostomy tube feedings. The findings include: According to the Electronic Health Record (EHR) R36 had diagnoses including Parkinson's Disease, protein calorie malnutrition, hypertension, gastroesophageal reflux disease, and acute embolism and thrombosis of left lower extremity. The Minimum Data Set (MDS) dated [DATE] showed R36 was totally dependent on one staff for feeding, and was receiving gastrostomy tube feedings. R36 was 69 inches tall and weighed 143 pounds on admission. The MDS showed R36's cognition was severely impaired. A Care Plan showed R36 had unplanned weight loss with interventions to contact the physician and dietitian immediately if weight decline persists. The Physician Order Sheet (POS) showed an…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2026-04-26 · tag F0803 — failed to meet residents' dietary needs — widespread
  Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to serve the correct protein entrees as planned per the facility approved menu.This applies to all 50 residents receiving regular, mechanical soft, low concentrated sweets, and no added salt diets in the facility. The findings include: Facility Daily Census, dated 4/24/26, shows the facility census was 58 residents.Facility Diet Type Report, dated 4/25/26, shows 7 residents received pureed diets, 1 resident had physician orders for NPO (Nothing By Mouth) and the rest of the residents received either regular, mechanical soft, low concentrated sweets or no added salt diets.On 4/25/26 at 10:29 AM, R1 (Resident Council President) stated residents were served very small entree portions such as small squares of fried fish at meals.On 4/25/26 at 11:45 AM, during lunch service, R2, R4, and R5 were served a bowl with mostly rice and few pieces of cut sausage and a few beans. There were no salt or pepper packets on the meal trays or table. On 4/25/26 at 12:20 PM, V8 (Cook) was serving 4 fluid ounces of jambalaya into…

  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 · F2026-04-26 · tag F0806 — failed to honor food preferences — widespread
  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 interviews and record reviews, the facility failed to offer residents a variety of appealing meal substitutions based on resident preferences per facility policy.This applies to all 57 residents receiving oral diets at the facility.The findings include: Facility Daily Census, dated 4/24/26, shows the facility census was 58 residents.Facility Diet Type Report, dated 4/25/26, shows one resident had physician orders for NPO (Nothing By Mouth).Facility Alternate Menu, undated, showed residents were offered the following substitutions if they were unsatisfied with their menu items served at meals: 1. Deli Sandwich; 2. Grilled Cheese; 3. Chef's Choice Salad with Italian or Catalina dressing; 4. White/Wheat/Rye Bread.On 4/25/26 at 10:29 AM, R1 (Resident Council President) stated residents were frustrated with the lack of meal substitution variety and were complaining at meals and during resident council meetings with no resolutions. R1 stated many residents do not like the food served at the facility and the meal substitution offered at the facility was limited to grilled cheese…

  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 · D2025-07-17 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to perform a pressure risk screen for a resident (R6) at risk for developing pressure ulcers, failed to ensure pressure-reducing interventions were implemented correctly for one resident (R6), and failed to perform weekly facility wound assessments for one resident (R5). These failures affected two of three residents (R5, R6) reviewed for pressure ulcers in the sample size of 6.Findings include:1. R6's face sheet documented an admission date of 11/07/2024, with a past medical history not limited to: hemiplegia and hemiparesis, aphasia, hypertension, type 2 diabetes mellitus and chronic kidney disease. Brief Interview for Mental Status (BIMS), dated 05/23/2025, indicated R6 has moderate cognitive impairment, with a score of 11/15.R6's care plan, with review start date of 05/27/2025, documented R6 is an extensive assist too dependent with activities of daily living (ADL's); has had pressure ulcer development related to disease process and impaired mobility; and has a wound to sacrum, and right/left buttock. Care…

  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 · F2025-04-23 · tag F0727 — failed to provide required RN coverage — widespread
  Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
  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 that an RN (Registered Nurse) was assigned to serve as a full time DON (Director of Nursing) to coordinate nursing care and supervision, to provide quality care to residents. This applies to all the 52 residents that reside at the facility. The findings include: The facility's CMS (Centers for Medicare & Medicaid Services) 671 (Long Term Care facility application for Medicare and Medicaid) dated April 15, 2025 showed the total resident at the facility was 52. On April 15, 2025 at 1:17 PM, V2 (Corporate Nurse) stated that the facility's designated DON had resigned, and she (V2) comes to the facility once a week, since the DON left. On April 17, 2025 at 2:15 PM, V1 (Administrator) stated that he received a text message from V14 (RN/former DON) on April 4, 2025 stating that she was not coming in the facility that day and that she (V14) will be sending an official letter of resignation by the end of the day. V14 stated that on April 7, 2025 he received a call from V14, informing him that she will be…

  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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-04-23 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure 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 follow sanitary practices in the facility kitchen. This applies to all 52 residents that received foods prepared in the facility kitchen. The findings include: Facility's CMS Form 671 dated April 15, 2025 showed that the facility census was 52 residents. Facility provided information that there were no residents on NPO (nothing by mouth) status. On April 15, 2025 at 09:20 AM, the initial tour of facility kitchen was done in presence of V4 (Dietary Manager). The hand sink area had unknown grime and had 2 scrub pads inside the sink that appeared to be used to prewash dishes at the dish machine. When questioned why the hand sink area was soiled, V4 stated that they do not have enough space in the kitchen to manage all tasks. The reach in, two door steel refrigerator in the kitchen had marked grime and unknown smears on the handle and the surface of the refrigerator. V5 (Cook) and V4 were seen opening and closing the refrigerator during meal prep and or service. There was a large pan inside the top shelf of the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-04-23 · tag F0880 — failed to prevent and control infections — widespread
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to provide hand hygiene during medication administration, failed to use PPE (Personal Protective Equipment) while providing direct care for a resident on EBP (Enhanced Barrier Precautions) and failed to do complete infection control surveillance monitoring for the facility. This applies to all 52 residents who reside in the facility. The Findings include: Facility's CMS Form 671 dated April 15, 2025 showed that the facility census was 52 residents. 1 On April 17, 2025, at 2:50 PM, V1(Administrator) stated V3 (MDS Nurse) was in the role of IP (Infection Preventionist) but was not trained. V3 was not in the facility and unavailable for interview. V1 provided the infection prevention surveillance documentation for January, February and March 2025, and V1 stated there was no infection surveillance the month of April 2025, and no residents who required TBP (Transmission Based Precautions). V1 provided the Infection Log the facility utilizes for tracking infection. The Infection Log included a column for documentation…

  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 · F2025-04-23 · tag F0881 — failed to use antibiotics responsibly — widespread
  Implement a program that monitors antibiotic use.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility had incomplete documentation on the Antibiotic Surveillance log and failed to evaluate the presence of infection utilizing the standardized criteria to define infections, in accordance with facility policy. This applies to all 52 residents who reside in the facility. The Findings include: On April 17, 2025, at 2:50 PM V1 (Administrator) stated he was unsure if the facility utilizes McGeer criteria or any criteria for evaluating the use of antibiotics. V1 provided Antibiotic Surveillance Log for the months of January, February and March 2025. V1 stated there was no Antibiotic Surveillance Log for the month of April 2025. V1 stated V3 (MDS Nurse) was assigned the role of IP (Infection Preventionist) but was not trained and was not available for interview. Upon request for the documents related to the facility Antibiotic Stewardship program the facility provided the policy and 3 months of Antibiotic Surveillance Logs. The Antibiotic Surveillance Log had 8 columns for data to be entered. The columns were titled: Date, Resident, Room #,…

  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 · F2025-04-23 · tag F0882 — widespread
  Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
  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 that the facility's IP (Infection Preventionist) had completed specialized training in infection prevention and control. This applies to all 52 residents who reside in the facility. The findings include: On April 17, 2025, at 2:50 PM, V1 (Administrator) stated the facility's trained IP was the former Director of Nursing, who last worked in the facility on April 4, 2025. V1 stated V3 (MDS Nurse) was assigned the duties of the IP. V1 became Administrator on February 24, 2025, and stated V3 was already assigned the IP position. V1 stated currently there is no staff onsite who completed specialized training in Infection Control. V3 had not received any specialized training in infection control. V3 was not available to be interviewed during this investigation. The infection control surveillance tracking that V1 provided for January, February and March 2025, was incomplete. There was no infection control surveillance tracking for the month of April 2025. The in-service training provided by the facility on infection control…

  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 · E2025-04-23 · tag F0656 — failed to write and follow a full care plan — pattern
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  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 have a comprehensive care plan, that identifies their individual needs and includes all aspects of their care including assistance needed with ADLs (Activities of Daily Living), urinary catheter care, oxygen administration, and wound care. This applies to 4 of 4 residents (R19, R51, R53 and R158) reviewed for care plans in the sample of 20. The findings include: 1. R19's admission record showed R19 was admitted to the facility on [DATE], with multiple diagnoses including diabetes type 2, essential hypertension, non-displaced fracture of head of right radius, major depressive disorder, obstructive sleep apnea, atherosclerotic heart disease. R19's MDS (Minimum Data Set) dated March 17, 2025, showed R19 had a stage 3 pressure ulcer, the presence of a pressure reducing device for bed, pressure reducing device for chair, and was receiving care and application of ointments for the pressure ulcer. R19's order summary dated April…

  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 · Ecited before2025-04-23 · 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 narcotic medication was stored in a sealed packaging. This applies to 4 of 4 residents (R2, R28, R37, R47) reviewed for controlled medications in the sample of 20. The findings include: On April 15, 2025, at 5:45 PM, the controlled medication was counted with V7 (Nurse/LPN), and the following were observed: 1. R37's blister pack of Tramadol HCl 50 mg (milligrams) number 8 and number 16 tablets, the seal of the packagings were broken. 2. R47's blister pack of Oxycodone 50 mg with 19 tablets remaining that were intact and sealed. R47's controlled drug receipt/record/disposition form for the Oxycodone showed that there should be 20 remaining in the blister pack. V7 stated that she gave the Oxycodone tablet to R47 earlier and has not signed it out yet. 3. R28's blister pack of Alprazolam 0.25 mg with 3 tablets left that were intact and sealed. R28's controlled drug receipt/record/disposition form for the Alprazolam showed…

  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

“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.

Fines & penalties

$212,548 in federal fines across 3 penalties. 1 Medicare payment denial on record.

• $24,395 — penalty dated 2026-03-12
• $115,837 — penalty dated 2025-07-17
• $72,316 — penalty dated 2025-04-23
• Medicare payment denial — starting 2025-05-16 for 32 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

CMS files one row per role, so the 6 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $988K 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

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