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Thrive Of Fox Valley

4020 E New York Street, Aurora, IL 60504 · For profit - Corporation · 68 certified beds · (331) 301-5590 Medicare & Medicaid certified

Call the home — (331) 301-5590 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 26 lower-level deficiencies on record (see below)
Insights

On the public record, this home looks stronger than most — but visit before you decide.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
Worth asking about
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
Urgent care / clinic
1 Fox Valley Ctr · (630) 820-5508 · Call to confirm hours
Pharmacy
3535 E New York St · (630) 961-1600 · Call to confirm hours
Grocery
4026 Fox Valley Center Dr · (773) 297-6308 · Call to confirm hours
Park
346 Cane Garden Cir · Typically dawn to dusk
Place of worship
4054 Fox Valley Center Dr · (630) 886-2002

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Short-stay residentsrehab / post-hospital 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Short-stay residents who newly got an antipsychotic medication1.2%2.2%1.4%better
Short-stay residents given the seasonal flu vaccine40.8%63.1%79.4%worse
Short-stay residents rehospitalized after admission27.9%26.1%22.6%worse
Short-stay residents with an outpatient ER visit14.5%13.9%12.0%worse

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.

71.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 730 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

71.5%U.S. median 51.5%
Got home and stayed home
11.0%U.S. median 10.7%
Went back to hospital
78.0%U.S. median 56.6%
Met the expected recovery
0.96U.S. median 0.31
Therapy hours / resident / day
0.53hours / resident / day
Physical therapy
0.36hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 78.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 328 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.96 therapist hours per resident per day in 2026Q1 — more than 96% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 38% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF71.5%CMS range 67.4–75.251.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.0%CMS range 9.0–13.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge78.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge67.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge50.6%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting99.8%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge94.5%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.3%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.8%CMS range 5.0–9.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.061.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

1.64
RN hours/ resident / day
0.65
LPN hours/ resident / day
1.67
Aide hours/ resident / day
3.95
Total nurse hours/ resident / day
1.18
RN hoursweekends
51.6%
Total nursing turnover
36.7%
RN turnover

How full it usually is: this home is certified for 68 beds and averages 65.8 residents a day — about 97% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.95 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.64 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.67 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.58 hrs/resident/day on weekends vs 4.10 on weekdays — 13% thinner on weekends. RN hours go from 1.82 to 1.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

6
deficiencies at the latest standard inspection (2024-07-26)
6
at the previous standard inspection (2023-08-24)

Deficiencies are unchanged from the previous inspection. 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.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

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

ABCDEFGHIJKL

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

26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.

  • Potential for harm · D2026-05-05 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a clean environment for residents. This applies to 3 of 5 residents (R1, R2, and R3) reviewed for housekeeping services in the sample of 5. Findings include:On May 4, 2026, at 9:30 AM, V3 (Housekeeper) stated it's impossible to get everything cleaned when they have only two housekeepers working on the floor. They have two housekeepers on the floor cleaning and one person in the laundry room today. V3 stated they have been working short and if the census drops, they will send staff home; however, with the third housekeeper gone, they still have the same amount of work to do. On May 4, 2026, at 10:18 AM V4 (Housekeeper) stated they normally have three housekeepers except when it's one of their days off or if someone calls off. V4 stated today is V12's (Housekeeper) day off. V4, stated sometimes they cut a housekeeper when the census drops but things are still dirty and need to be cleaned. V4 stated that when there are only 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-01 · 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 provide educational instructions for a resident (R5) discharging with a cardiac monitor.This applies to 1 of 4 residents (R5) reviewed for discharges.The findings include:R5's EMR (Electronic Medical Record) said he was admitted to the facility on [DATE] with multiple diagnoses, including a new onset of cardiomyopathy, which required the use of a cardiac vest monitoring device. R5's MDS (Minimum Data Set) dated 3/20/2026 said he was cognitively intact and able to follow instructions. The EMR said he was discharged home on 3/20/2026, still requiring the use of the monitor.On 4/01/2026 at 12:30 PM, V21 (Registered Nurse/RN) said she readmitted R5 on 3/06/2026 and routinely cared for R5 during his stay at the facility. V21 said R5 did not have cardiac monitoring orders during his stay, and she forgot to enter them when he was readmitted . V21 said the orders were needed to ensure the monitor was checked to be working properly every shift. V21 said R5'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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-01 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess and treat a resident's (R2) skin conditions as ordered.This applies to 1 of 3 residents (R2) reviewed for skin care.The findings include:R2's care plan said she had actual and was at risk for further skin impairment due to her left lower leg cellulitis and chronic lymphedema. The care plan's interventions included for the nursing staff to evaluate and treat her skin as ordered. R2's MDS (Minimum Data Set) dated 3/25/2026 said she was cognitively intact. R2's EMR (Electronic Medical Record) showed she had an active order for Nystatin powder (antifungal) to be applied to under her breast twice a day and wound consults as needed.On 3/27/2026 at 11:40 AM, R2 said she was upset and frustrated because on the evening of 3/26/2026, she requested V5 (Registered Nurse/RN) to assess her new open wound to her left anterior thigh but V5 did not assess or treat her wound. R2 said she was concerned regarding skin impairment because she 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to safely transport a resident (R1) in a wheelchair, resulting in him falling and sustaining multiple lacerations.This applies to 1 of 3 residents (R1) reviewed for accidents.The findings include:R1's EMR (Electronic Medical Record) showed he was admitted to the facility on [DATE] with multiple diagnoses, including chronic renal failure, dependent on hemodialysis, unsteadiness on his feet, need for assistance with personal care, reduced mobility, and glaucoma. R1's MDS (Minimum Data Set) dated 1/22/2026 said he was cognitively intact and was dependent with his transfers and lower body care needs. R1's Fall Risk Evaluation dated 1/15/2026 said he was at a high risk for falls. The EMR said he was transferred to the hospital on 3/11/2026 after he sustained a witnessed fall and did not return to the facility.On 3/31/2026 at 1 PM, R1 was interviewed over the phone. R1 said on 3/11/2026, V10 (Certified Nurse Assistant/CNA) was wheeling him in a wheelchair down…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-01 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to administer a resident's (R2) as needed analgesic when requested.This applies to 1 of 3 residents (R2) reviewed for pain management.The findings include:R2's care plan said she had the potential for pain due to her chronic pain syndrome. The care plan had multiple interventions, including her need to receive her opioid medication as ordered. Also, for the staff to anticipate her need for pain relief and respond immediately to any complaint of pain. R2's MDS (Minimum Data Set) dated 3/25/2026 said she was cognitively intact. R2's EMR (Electronic Medical Record) showed she had an active order for Norco (analgesic) 10-325 mg (milligrams) one tablet every six hours as needed for pain.On 3/27/2026 at 11:40 AM, R2 said she was upset and frustrated because on the evening of 3/26/2026, she called to request Norco and did not receive it when requested. R2 said V7 (CNA/Certified Nurse Assistant) responded to her call light multiple times after she continued to call repeatedly for her medication. R2 said V7 informed her she 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-18 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to assess, monitor, document, and care plan a resident with a cholecystostomy drain and failed to provide care and services for a resident needing staff assistance for 2 of 4 residents (R2, R4) reviewed for quality of care in the sample of 4. The findings include: 1. On 3/18/25 at 11:06 AM, R4 was sitting up in a wheelchair in her room. R4 had a cholecystostomy drainage bag sitting next to her in the wheelchair. R4 stated she had a gallbladder attack in hospital and the bag is from that. R4 stated there is some drainage into the bag and the nurses drain it. R4 lifted her shirt and showed this surveyor the cholecystostomy incision site on the right side of her abdominal area. R4's incision site had gauze covering the insertion area with the drainage tube coming out. The gauze was covered with a transparent dressing. The gauze had a nickel size dried brownish red area of drainage around the drainage tube. There was no date on either dressing.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-15 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to have clear resident care policies to ensure a resident's neurological evaluations were completed and monitored after an unwitnessed fall. This applies to 1 of 3 residents (R1) reviewed for quality of care in a sample of 5. Findings include: R1's Face Sheet showed she was admitted on [DATE] with diagnoses that included personal history of pulmonary embolism, other pulmonary embolism with acute cor pulmonale, personal history of transient ischemic attack (TIA) and cerebral infarction without residual effects. R1's MDS (Minimum Data Set) showed moderate cognitive impairment. R1's 10/4/2024 progress note written by V13 (on-call Physician) from 9:00 PM showed she experienced an unwitnessed fall and was on a blood thinner. The Orders section showed Assess pain per protocol and Monitor with neuro-checks per protocol. The facility's Post-Fall policy (revised 5/2023) showed If the resident reports hitting head, if there is any indication of head injury, or 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-30 · tag F0585 — failed to handle grievances — isolated
    Honor 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 resolve Resident Council and individual resident's concerns regarding extended wait times for call light response. This applies to 3 of 3 residents (R1, R2, and R4) reviewed for improper nursing care related to call light response times, in the sample of 4. The findings include: The Resident Council Meeting Minutes dated May 23, 2024, showed . 7. Guests (residents) voiced they take a long-time answering call light. Resolution: This was communicated to Director of Nursing and Administration There were 6 patients (residents) in attendance at the meeting. The Resident Council Meeting Minutes dated June 26, 2024, attended by 5 patients (residents), showed under New (business) .1. Guest (resident) complained about the call lights not being answered quickly and voiced she understands the aides have a lot of people to take care of, but facility can get more help for CNAs and nursing would be great. The Resident Council Meeting Minutes dated July 24, 2024,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-07 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to administer medications timely in accordance with the facility policy. This applies to 2 of 3 (R2, R4,) in a sample of 3 reviewed for timely administration of medications. The findings include: R4's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including [NAME] Barre Syndrome, [NAME] Nile virus, pulmonary embolism without acute cor pulmonale, And generalized muscle weakness. R4's MDS (Minimum Data Set) dated July 23, 2024, showed R4 was cognitively intact, and was dependent on staff assistance with ADLs including eating, oral hygiene, bed mobility, bathing, dressing, toilet hygiene, and transfer. R4's Medication Administration Audit report, dated July 26, 2024-July 27, 2024, showed R4 medication scheduled to be administered at 9:00 AM, included Amlodipine Besylate tablet 2.5 mg, (milligrams) daily, Metoprolol Tartrate tablet 25 mg, twice a day, Apixaban 5 mg. twice a day, Aspirin 81 mg. daily,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-07-26 · 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 properly label, date, seal, and store food items in the kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 7/23/24 documents that the total census was 57 residents. On 7/25/24 at 12:14 AM, V11 (Dietician) said there are zero NPO (Nothing by Mouth) residents that do not eat from the facility kitchen. On 7/23/24 starting at 9:55 AM, the facility kitchen was toured in the presence of V9 (Dietary Manager). V9 stated, frozen items can be used for six months from the date it is received. The following expired items were observed in the refrigerator/freezer: 1. Feta Cheese, crumbled, 2 bags of 5 lbs each with received date of 1/13/23. 2. Cheese Ravioli 2 bags of 5 lbs each with received date of 11/10/23. 3. Chopped Spinach 12 bags of 2 lbs each with received date of 11/14/23. 4. Eggo Frozen waffles: 5…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · Dcited before2024-07-26 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably 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 provide a resident with a functioning over bed light and failed to provide an adaptive call/light button. This applies to 2 (R26, R31) of 2 residents reviewed for accommodation of needs in a sample of 19. Findings include: 1. R26 was admitted to the facility on [DATE] with diagnoses that include displace comminuted fracture of shaft of humerus of right arm, moderate protein calorie malnutrition, polyneuropathy, intrahepatic bile duct carcinoma, secondary neoplasm of right lung, hyperlipidemia, hypothyroidism, muscle weakness, depression, and anxiety. On 07/23/24 at 11:42 AM, R26's call light was hanging on the left side of her bed near the floor out of her reach. R26 stated her hands are paralyzed and she has macular degeneration. R26 stated she has difficulty pressing the call light button. R26 stated she requires assistance with everything, but she doesn't think the staff is completely aware of her care needs. R26 stated she has waited…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-26 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to provide timely incontinence care. This applies to 1 (R26) of 3 residents reviewed for assistance with ADLs (Activities of Daily Living) in a sample of 19. Findings include: R26 was admitted to the facility on [DATE] with diagnoses that include displace comminuted fracture of shaft of humerus of right arm, moderate protein calorie malnutrition, polyneuropathy, intrahepatic bile duct carcinoma, secondary neoplasm of right lung, hyperlipidemia, hypothyroidism, muscle weakness, depression, and anxiety. On 07/23/24 at 11:42 AM, R26 stated she requires assistance with everything, but she doesn't think the staff is completely aware of her care needs. R26 stated the first time she saw staff was at 10:40 AM and she was not provided incontinence care at that time. R26 stated she had been in the same soiled undergarment since the previous night. On 07/23/24 at 11:56 AM, after surveyor request V5 LPN (Licensed Practical Nurse) and V6 RN (Registered Nurse) assisted…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-26 · 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 observation, interview, and record review the facility failed to ensure the residents received their medications per physician's orders and resident's choices for 2 of 2 residents (R260 and R262) reviewed for medication administration in the sample of 19. Findings include: 1. On 7/23/24 at 12:25 PM, R260 was sitting on her WC (wheelchair) next to her bed. R260 stated, she had not received her Trospium 20 mg since she was admitted to the facility, i.e. about eight days. R260 stated, she had been on Trospium for past one to two years and that she needed it for urinary incontinence. R260 stated, she ensured that the medicine was listed on the discharge documents from the hospital and hence the facility knew that she was on this medicine before she arrived at the facility. R260's face-sheet showed an admission date of 7/15/24 with multiple diagnoses including Multiple Sclerosis, Urge incontinence and Anxiety. R260's MDS (Minimum Data Set) dated 7/22/24 showed she was cognitively intact. R260's Progress Notes showed: 7/16/24 10:26 AM Trospium Chloride Oral Tablet 20 MG Give 1…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the resident received respiratory care services that are in accordance with professional standards of practice for 3 of 3 residents (R15, R20 and R265) reviewed for respiratory therapy in the sample of 19. Findings include: 1. On 7/23/24 at 12:20 PM, R15 was sitting on his WC (wheelchair) next to his bed. Observed R15's CPAP (continuous positive airway pressure) mask with tubing not in use and not contained in a bag. On 7/24/24 at 10:00 AM, observed R15's CPAP mask with tubing not in use and not contained in a bag. R15's face sheet provided by the facility on 7/25/24 showed he was last admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease and Asthma. R15's Physician order report for July 2024 showed, CPAP/BiPAP (bilevel positive airway pressure) at bedtime and in the morning cleanse mask and allow to air dry after removal. 2. On 7/23/24 at 1:00 PM, R20 was in semi-Fowler's position in…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-26 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to administer ordered intravenous antibiotics for residents with infections. This applies to 2 of 4 residents (R3 and R44) reviewed for intravenous medications in a sample of 19. Findings include: 1. R3's EMR (Electronic Medical Record) showed R3 was to be receiving vancomycin IV (intravenous) antibiotic for MRSA (Methicillin-resistant Staphylococcus aureus) bacteremia infection. On 7/25/2024 at 2:29 PM, V12 (Pharmacist) stated she was dosing R3's vancomycin IV antibiotic medication as ordered by his provider. V12 stated patients receiving vancomycin IV require their medication therapeutic blood levels to be closely monitored because if too high the medication could be toxic or if too low it could be nontherapeutic. V12 stated she determines a patient's target tr (trough) blood medication level range based on the type of infection being treated to ensure the medication is effective. V12 stated vancomycin IV dosages and frequencies are then adjusted based on the patient's tr results. V12 stated R3 had an order to start…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-28 · tag F0691 — failed to provide colostomy / ostomy care — isolated
    Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure ostomy care was provided in a manner to prevent skin irritation. This applies to 1 of 2 residents (R1) reviewed for ostomies in the sample of 7. The findings include: R1's face sheet shows he is a [AGE] year-old male admitted to the facility on [DATE]. R1's diagnoses include end stage renal failure, dependence of renal dialysis, acute respiratory failure with hypoxia, orthostatic hypotension, ileostomy status, gout, pain in right foot and primary osteoarthritis in right foot and ankle. On 5/22/24 at 12:02 PM, V5 (RN) stated R1's ostomy would leak often, his appliance would have to be changed two to three times a shift. Sometimes we would use tape to reinforce it to the skin. There was skin irritation around R1's stoma site. R1 would report burning around the site. On 5/22/24 at 1:04 PM, V16 (Licensed Practical Nurse-LPN) stated R1's ostomy was leaking a lot, sometimes we would have to change it two to three times a shift. R1 report burning around…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-02 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a CPAP machine (continuous positive airway pressure machine) was operated as ordered by the physician for 1 of 3 residents (R1) reviewed for CPAP machines in the sample of 3. The findings include: R1's face sheet printed on 11/2/23 showed an admission date of 10/25/23 and diagnoses including but not limited to atherosclerosis of left leg arteries, right side paralysis, heart disease, diabetes mellitus, aphasia (difficulty speaking), and need for assistance with personal care. R1's facility assessment dated [DATE] showed severe cognitive impairment and the use of a CPAP machine. R1's admission progress note dated 10/25/23 stated the physician was notified of the new admit, diagnoses of recent left femoral popliteal bypass surgery, left great toe ulcer, staples to surgical incision to left lower leg, and left groin incision. The note showed orders for lab work to be done in the morning. R1's order summary report showed an order start dated 10/25/23…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-24 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow their policy for assessment of a resident's surgical wounds and failed to follow physician orders for wound/incision care. This applies to 1 of 3 residents (R2) reviewed for wounds in the sample of 7. The findings include: The EMR (Electronic Medical Record) shows R2 was admitted to the facility on [DATE], and was discharged to the local hospital on April 10, 2023. R2 did not return to the facility. R2 had multiple diagnoses including, malignancy of the vulva, Sjogren syndrome (autoimmune disease), hypogammaglobulinemia (low antibody levels), diabetes, rheumatoid arthritis, polyneuropathy, muscle weakness, unsteadiness on feet, restless legs syndrome, and depression. R2's MDS (Minimum Data Set) dated April 10, 2023, shows R2 was cognitively intact, was able to eat with supervision, required limited assistance with walking, locomotion and personal hygiene, and extensive assistance with bed mobility, transfers between surfaces and toilet use. R2…

    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 · E2023-08-24 · tag F0805 — failed to prepare food in a form residents can eat — pattern
    Ensure 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 serve pureed and mechanical soft diet consistencies to residents with diet orders for the same. This applies to 5 of 5 residents (R1, R7, R11, R27, R99) reviewed for dining in the sample of 17. The findings include: On August 22, 2023 at 11:42 AM, V5 (Cook) was observed preparing pureed meals in the facility kitchen. V5 stated that he is pureeing the lunch meal consisting of Greek marinated chicken and green beans for 2 residents (R1 and R11) based on production sheet. V5 stated that he is serving cream of rice instead of pureeing the rice. During the pureeing process, V5 added three pieces of chicken (about 4 oz each piece) into a blender with minimal amount of broth and pureed the same. The final product appeared granular with uneven texture. V5 put two 4 oz scoops of cooked green beans into another blender and pureed the same with minimal broth and thickener. The final product had small pieces of green beans that were not able to be mashed in between the fingers. Prior to transferring into service bowls, V4…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-24 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably 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 and interview, the facility failed to provide a bed that could comfortably accommodate a resident. This applies to 1 of 1 resident (R19) reviewed for accommodation of needs in the sample of 17. The findings include: R19's EMR (Electronic Medical Records) included that R19 was recently admitted on [DATE] and discharged to the hospital on August 15, 2023 and subsequently readmitted on [DATE]. R19's face sheet included diagnoses of malignant neoplasm of upper lobe, right bronchus or lung, secondary malignant neoplasm of brain, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease,difficulty in walking, not elsewhere classified, cognitive communication deficit, pain in right ankle and joints of right foot, spinal stenosis, cervical region, cervicalgia. R19's admission MDS (Minimum Data Set) dated August 9, 2023 showed that R19 was moderately impaired in cognition and required extensive assistance of one person for bed mobility and transfers. R19's height recorded on…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-24 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have a Physician's order for the care of a PICC (peripherally inserted central venous catheter) and failed to provide PICC insertion site dressing changes and monitoring in accordance with facility policy. This applies to 1 of 3 residents (R24) reviewed for intravenous catheters in the sample of 17. The findings include: On August 21, 2023, at 10:45 AM, R24 was observed with a PICC on the right upper arm. There was a transparent dressing covering the site and the date on the label was unable to be read. R24 stated the PICC line was put in while he was in the hospital and the facility staff had never changed the dressing. R24's face sheet showed R24 was admitted to the facility on [DATE], with multiple diagnoses included osteomyelitis of right foot, cellulitis of the right lower limb, unspecified atrial fibrillation, atherosclerotic heart disease, and chronic kidney disease. R24's MDS (Minimum Data Set) dated August 3, 2023, showed R24…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-24 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure that oxygen was delivered to a resident at the prescribed dosage. This applied to 1 of 1 resident (R201) reviewed for oxygen in the sample of 17. The findings include: R201's face sheet included diagnoses of chronic obstructive pulmonary disease, unspecified, pulmonary hypertension, unspecified, difficulty in walking, not elsewhere classified, other reduced mobility, displaced fracture of base of neck of left femur, subsequent encounter for closed fracture with routine healing. R201's 5 day MDS (Minimum Data Set) dated August 8, 2023 showed that R201 was cognitively intact. R201's POS (Physician Order Sheet) included: May administer 2L (liters) supplemental Oxygen as needed (start date August 1, 2023). R201's care plan revised on August 21, 2023 included that R201 has altered respiratory status/difficulty breathing related to Congestive heart Failure, Chronic Obstructive Pulmonary Disease, Heart Failure. Interventions for the same included supplemental oxygen as ordered by Medical Doctor. On August 21,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-24 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to perform comprehensive pain assessment and develop an individualized plan of care to manage the resident's pain. This applies to 1 of 3 residents (R300) reviewed for pain management in the sample of 17. The findings include: On August 21, 2023, at 11:03 AM, R300 was in bed, with facial grimacing, and stated she does not feel comfortable, stated her pain score was 7 out of 10. On August 22, 2023, at 10:13 AM, R300 stated her pain goal is 3 out of 10. R300's admission record showed R300 was admitted to the facility on [DATE], with multiple diagnoses including, aftercare following joint replacement surgery (right), presence of artificial left hip joint, diabetes mellitus, long term use of insulin, low back pain, unspecified, and essential hypertension. R300's nursing evaluation dated August 16, 2023, showed R300 is alert and oriented to person, place, time, and situation and requires assistance with ADLs (Activities of Daily Living). R300's…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-24 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to administer medications as ordered by the physician. There were 25 opportunities with 2 errors, resulting in an 8% medication error rate. This applies to 1 of 6 residents (R300) observed during the medication pass in the sample of 17. The findings include: On August 22, 2023 at 9:11 AM, during medication pass, R300 complained of shortness of breath, feeling tired and wheezing. R300 requested to receive her inhaler. V12 (Registered Nurse) prepared and administered multiple medications to R300, including Albuterol AER HFA (aerosol hydrofluoroalkane) inhaler. V12 administered two puffs/inhalation of the Albuterol inhaler to R300 consecutively without waiting for at least one minute in between inhalations. On August 22, 2023 at 10:01 AM, during medication pass, V12 applied Erythromycin ophthalmic ointment on the skin around R300's eyes. V12 did not pull down R300's lower eye lid to apply the ophthalmic ointment. R300's active order summary report showed following orders dated August 16, 2023, Albuterol Sulfate HFA…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-10-14 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow proper sanitation, complete required log sheets, and remove expired items. This applies to all residents receiving oral nutrition and foods prepared in the facility kitchen. Findings include: Facility Resident Census and Condition of Residents (Form CMS--Centers for Medicare and Medicaid Services--672), dated 10/13/22, documents the total census was 58 residents. V2 (DON-Director of Nursing) stated there was only 1 resident with gastrostomy tube feeding. On 10/11/22 at 10:56 AM, surveyor entered the kitchen and washed his hands in the handwashing sink. There were no paper towels in the paper towel dispenser which was locked. V4 (Head Cook) stated, I don't know where the key is to the dispenser. I believe the previous manager has it. The kitchen tour was conducted with V4 and V3 (Dietician). V3 stated that the previous dietary manager quit a couple of weeks ago and that V4 is covering until the dietary manager starts on 10/24/22. 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-10-14 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    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 obtain vital information regarding residents' pacemakers and ensure that it was readily available in the resident's medical record. This applies to 4 out of 4 residents (R95, R244, R248, R250) reviewed for pacemakers in a sample of 16. Findings include: 1. R95's face sheet documents an admission date of 10/3/2022. R95's face sheet documents the following diagnoses: Hyperlipidemia, Hypertension, Nonrheumatic Aortic Valve Stenosis and Presence of cardiac pacemaker. R95's medical record was reviewed. There was no physician order documenting the pacemaker and how often it should be checked. There was nothing in the progress notes, admission assessment or care plans that document the manufacturer, model, and serial number of the pacemaker. It was also unknown as to when the pacemaker was last assessed. 2. R244's face sheet documents an admission date of 10/3/22. R244's face sheet document the following diagnoses: Chronic Diastolic (Congestive) Heart Failure, Personal History of other Venous Thrombosis and Embolism, Personal…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
IH KCB FOX VALLEY, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 12/19/2019
CLOCH FAMILY TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; GENERAL PARTNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/19/2019
IH FOX VALLEY LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; GENERAL PARTNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/19/2019
KCB REAL ESTATE VII LPOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; LIMITED PARTNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/19/2019
S/K PARTNERSHIPOrganizationINDIRECT OWNERSHIP INTERESTsince 12/19/2019
CLOCH, BRIANIndividualINDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; GENERAL PARTNERSHIP INTEREST; ADP OF THE SNFsince 12/19/2019
HABER, BRADLEYIndividualINDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; GENERAL PARTNERSHIP INTEREST; ADP OF THE SNFsince 12/19/2019
BURNS, SHONDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/16/2025
YOUSUF, MOHAMMEDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2020
BRADLEY S HABER REVOCABLE TRUST UAD OCTOBER 15 2013OrganizationGENERAL PARTNERSHIP INTERESTsince 12/19/2019
LOCKWOOD INVESTMENTS LLCOrganizationLIMITED PARTNERSHIP INTERESTsince 12/19/2019

CMS files one row per role, so the 26 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.

7 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

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

$13.5M
Net patient revenuemost recent cost report
+13.2%
Operating marginrevenue minus expenses
$1.2M
Related-party expense10% of expenses
Who pays — share of resident-days
Medicaid 0%Medicare 55%Other / private 44%

This home reported $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 10% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$549per resident / day
operating cost
$16,690per month
≈ monthly operating cost
$633per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in IL

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.

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

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 146194. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-07-26, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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