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Pavilion Of Bridgeview, The

8100 South Harlem Avenue, Bridgeview, IL 60455 · For profit - Limited Liability company · 146 certified beds · (708) 594-5440 Medicare & Medicaid certified

Call the home — (708) 594-5440 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0605) — cited Dec 20251 actual-harm citation
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)
  • about 17% of its spending goes to commonly-owned related companies

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

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

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
7945 S Harlem Ave · (708) 422-7100 · Call to confirm hours
Pharmacy
7878 S Harlem Ave · (708) 496-7806 · Call to confirm hours
Grocery
8339 S Harlem Ave · (708) 430-0669 · Call to confirm hours
Park
7303 W 83rd St · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 2 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 3 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 rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased10.1%13.4%15.4%better
Long-stay residents who lose too much weight6.9%6.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.3%0.9%0.9%better
Long-stay residents with a urinary tract infection0.0%1.5%2.0%better
Long-stay residents with depressive symptoms99.8%54.2%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury0.2%3.1%3.3%better
Long-stay residents whose ability to walk worsened10.1%14.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication8.2%18.3%18.9%better
Long-stay residents given the seasonal flu vaccine75.7%91.8%95.3%worse
Long-stay residents with pressure ulcers6.8%4.8%4.7%worse
Long-stay residents with worsening bladder/bowel control24.9%20.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table22.6%21.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.9%2.2%1.4%better
Short-stay residents given the seasonal flu vaccine14.1%63.1%79.4%worse
Short-stay residents rehospitalized after admission43.6%26.1%22.6%worse
Short-stay residents with an outpatient ER visit5.4%13.9%12.0%better
Long-stay hospitalizations per 1,000 resident days2.752.021.67worse
Long-stay outpatient ER visits per 1,000 resident days1.422.221.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

31.4% 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 94 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

31.4%U.S. median 51.5%
Got home and stayed home
11.9%U.S. median 10.7%
Went back to hospital
16.7%U.S. median 56.6%
Met the expected recovery
0.26U.S. median 0.31
Therapy hours / resident / day
0.10hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 16.7% 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 54 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 0.26 therapist hours per resident per day in 2026Q1 — more than 38% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% 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 SNF31.4%CMS range 23.8–39.151.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.9%CMS range 8.5–16.210.7%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 discharge16.7%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 discharge16.7%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 discharge14.8%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.1%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.8%CMS range 5.0–12.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.571.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.62
RN hours/ resident / day
0.60
LPN hours/ resident / day
2.02
Aide hours/ resident / day
3.23
Total nurse hours/ resident / day
0.52
RN hoursweekends
46.3%
Total nursing turnover
34.8%
RN turnover

How full it usually is: this home is certified for 146 beds and averages 130.3 residents a day — about 89% occupied, or roughly 16 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.23 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.62 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 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 2.98 hrs/resident/day on weekends vs 3.34 on weekdays — 11% thinner on weekends. RN hours go from 0.65 to 0.52 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%.

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

Inspection trend

10
deficiencies at the latest standard inspection (2025-12-04)
1
at the previous standard inspection (2024-10-03)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.

  • Actual harm · Gcited before2025-04-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a resident with adequate staff supervision during a shower for a resident who requires substantial maximal assistance with bathing/showering. This failure applies to one of three residents (R2) reviewed for accidents/supervision and resulted in R1 sustaining a femur fracture. Findings include: R2 has a diagnoses history of Paraplegia, Multiple Sclerosis, Morbid Obesity, and Cognitive Communication Deficit who was admitted to the facility 04/06/2024. The facility's Incident Investigation Report dated 04/09/2025 documents on 04/01/2025 R2 was taken for her regularly scheduled shower, she was set up with her items per usual with the shower chair locked, she reported she dropped the towel and when she reached down to grab the towel, she slid from the shower chair; Upon interview with the CNA (Certified Nursing Assistant) stated she set the resident up per her request, lathered the soap and towel and allowed her privacy per the resident's request;…

    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 · D2026-06-18 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to treat a resident in a dignified manner and ensured that (R1) had on clothing attire when resting in bed. This affects one of three residents (R1) reviewed for improper nursing care. R1 face sheet shows R1 has dementia. R1 MDS shows R1 is dependent on staff assistance for activities of daily living for dressing. R1 observed resting in bed awake and alert, R1 was not interview able. R1 was dressed in a orange gown/dress. 6/17/26 at 11:47am V5 (R1 power of attorney) said on Mother's day when she visited R1, R1 was observed with no clothing on while resting in bed, only the linen was covering R1 body. V5 said she made V2 (DON) aware. V5 sent photos showing R1 without clothing and resting on soiled linen. 6/17/26 at 1:00pm V2 (Director of Nursing) said V5 made her aware that R1 did not have on clothing during her visit with R1 on mother's day, V2 said her expectation is that the residents are cleaned and dressed as they desired. V2 said R1 has never requested to be unclothed under her blanket. The resident rights for people…

    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 · F2025-12-04 · 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 ensure that food kept in the refrigerator was labeled with open and use by date to prevent food borne illness and failed to ensure kitchen staff beards and hair were covered with required hair net and beard guard. This failure has the potential to affect 128 residents. Findings include:On 9/29/2025 between10:04am to 10:10am, during kitchen observation with V10, Dietary Manager, 2 quarter pans of pureed eggs dated 09/26/25 not specifying whether it is open date or used by date. V10 stated it is pureed eggs, and it does not have a used by date. I (V10) cannot see a used by date that must be the prepared date. V10 stated the cook should have put the used by date to show that this is the prepared date. During the same observation 1/2 quart eggs dated 9/28/25 not specifying whether it is open date or used by date. V11, Dietary Aide observed with long beard without beard guards or hair net. V10 stated that all hair should be covered with hair nets and beard guard.Facility policy Hair Restraints/Jewelry/Nail Polish…

    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 · F2025-12-04 · tag F0921 — failed to keep a safe, functional, sanitary building — widespread
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to clean and maintain the dryer lint screens thoroughly to provide a safe environment for the residents. This failure has the potential to affect all 131 residents at the facility.Findings include:Facility census, dated 12/01/25, documents 131 residents residing at the facility.On 12/02/2025 at 12:20pm, during a tour of the laundry area with V9 (Housekeeping Manager), 4 dryers were observed. V9 opened the lint compartment of dryer #4. The lint compartment floor had a large amount of loose lint on the floor and the lint screen was fully covered with lint. Dryer #3 had a sign stating that the dryer did not work and V9 confirmed that dryer#3 was not working properly and not in use. V9 opened the lint compartment of dryer #2. The lint compartment floor had loose lint on the floor and the lint screen was fully covered with lint. V9 opened the lint compartment of dryer #1. The lint compartment floor had a large amount of loose lint on the floor and the lint screen was fully covered with lint. V9 said, These (lint…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-04 · tag F0605 — failed to not use drugs as a restraint — pattern
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    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 policy and procedure and failed to use and follow a valid PRN (as-needed) order for four residents (R9, R39, R122, and R147) receiving psychotropic medications, as required by federal regulations and facility policy. These failures affected 4 residents (R9, R39, R122, and R147) in a sample of 57 residents reviewed for psychotropic medications.Findings include: R9 's medical record showed that R9 was admitted to the facility [DATE] with diagnosis list that includes but not limited to Chronic obstructive pulmonary disease, type 2 diabetes mellitus with ketoacidosis without coma, delusional disorder, restlessness and agitation, major depressive disorder, and retention of urine. On hospice care. R9's MDS (Minimum Data Set) dated [DATE] scored BIMS (Brief Interview for Mental Status) at 03 indicating at R9 is cognitively impaired. Section E coded 0 for behavior R9's medical record MAR (Medication Administration Record) E-POS (Electronic Physician…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-04 · tag F0645 — pattern
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 preadmission screening assessments were completed as required for residents identified that have a mental illness. This failure affected four residents (R4, R5, R59, and R124) reviewed for pre-admission screening in the sample list of 57 residents. Findings include: R4 is [AGE] years old and have resided at the facility since 2021, past medical history include, but not limited to pot traumatic stress disorder, bipolar disorder current episode mixed, unspecified, major depressive disorder recurrent, unspecified, type 2 diabetes, etc. R4 has an MDS indicator for no PASARR 11 with diagnosis of post-traumatic stress disorder (PTSD), bipolar disorder and major depressive disorder. On 12/03/2025 at 9:30AM, requested resident's PASRR screening from the facility and they provided a copy of Federal Omnibus Budget Reconciliation Act (OBRA) pre-admission screening dated 01/03/2021. Surveyor requested for resident's PASARR screening from Maximus and V2…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-12-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that chemical sprays were safely locked up when not in use by authorized facility staff to prevent accidental use by residents with diagnosis that includes respiratory disease/compromise for five of five residents (R9, R21, R66, R70, R117) reviewed for hazards and supervision. This failure affected five of five residents (R9, R21, R66, R70, R117) and has the potential to affect all 43 residents residing on the 2nd floor of the facility.Findings include:R9 's medical record showed that R9 was admitted to the facility 04/09/2024 with diagnosis list that includes but not limited to Chronic obstructive pulmonary disease, type 2 diabetes mellitus with ketoacidosis without coma, delusional disorder, restlessness and agitation, major depressive disorder, and retention of urine.R21's medical record admission record showed that R21 was admitted [DATE] with listed diagnosis that includes but not limited to Chronic obstructive disease, type 2…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-04 · 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 properly document medication administration of controlled medications on the controlled drug receipt/record/disposition form for three residents (R32, R63, and R140) and failed to properly document shift change accountability on the controlled substances check form per facility policy. These failures have the potential to affect 22 residents on 2nd, 18 residents on 3rd, and 15 residents on 4th floor that receive controlled medications reviewed during medication storage review.Findings include:On 09/29/2025 at 10:42 AM, the 4 [NAME] medication cart was reviewed with V12 LPN. The shift change accountability for controlled substances record has missing nurse initials for 09/21/25 on 2nd and 3rd shift.R140's controlled drug receipt record/disposition form documents Hydrocodone-Acetaminophen *Controlled Drug* Oral Tablet 5-325 mg (milligrams) give 1 tablet by mouth every 8 hours as needed for pain. Review of R140's controlled drug receipt record/disposition form documents 15 tabs remain. The count 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-04 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to 1. ensure a resident had a physician's order to keep a prescribed inhaler at the bedside for one (R21) resident, 2. failed to remove expired stock Loratadine medication and two unlabeled prescription Fluticasone/Salmeterol oral inhalation Diskus from the medication cart. This failure has the potential to affect 43 residents receiving medication on the 2nd and 4 residents (R24, R91, R92, and R124) receiving Loratadine stock medication on the 4th floor during medication storage review. On [DATE] at 10:31am, R21 was sitting in their wheelchair with Fluticasone propionate nasal spray noted on the bedside table with no label no name and not in manufacturer packet and no pharmacy labeled package. R21 stated that it is mine and I (R21) use it all the time. The nurse gave it to me. It's mine. When the surveyor made V6 (Nurse) aware and shown the medication and was asked about the facility policy on medication administration that includes…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-04 · 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 admission criteria policy by failing to ensure that staff obtained information needed for the care of one resident from the attending physician prior to admission, failed to ensure that staff follow their medication administration policy by failing to administer prescribed diabetic medications and failed to notify the physician that medication was not available. This failure affected one (R135) of one resident reviewed for quality of care. R135 was admitted to the facility from the hospital, alert and oriented and was found unresponsive and cold to touch at the facility the following day. Death certificate listed cause of death as hypertension and diabetes mellitus.Findings include:R135 [AGE] years old admitted to the facility on [DATE], face sheet listed the following past medical history among others; type 2 diabetes with hyperglycemia, acute cystitis with hematuria, essential primary hypertension, mixed hyperlipidemia, hypotension…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-04 · 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 have a five percent (5%) or lower medication error rate. There were 3 medication errors out of 33 medication opportunities resulting in a 9% medication error rate for 3 (R70, R79, and R129) residents reviewed during medication administration. This failure has the potential to affect all 131 residents in the facility.Findings include:On 09/30/2025 at 08:14 AM V17 LPN Licensed Practical Nurse signed out each medication as administered after preparing the medication prior to them being administered to R70. On 09/30/2025 at 08:30 AM, V17 administered 1 tablet of Senokot S Oral Tablet 8.6-50 mg (milligrams) to R79. R79's physician order states: Give 2 tablet by mouth one time a day for Constipation. On 09/30/2025 at 08:44 AM, V17 prepared R129's Senexon-S Tablet 8.6-50 MG give 2 tablet by mouth every 12 hours for Constipation. V17 only prepared 1 tablet for administration. On 09/30/2025 at 08:46 AM, V17 LPN prepared R129's Metamucil 4 in 1 Fiber Oral Packet (Psyllium) give 1 packet by mouth one time a day for…

    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
Show the remaining 20 citations
  • Potential for harm · Dcited before2025-12-04 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to follow their policy for infection control related to 1. Failed to clean glucometer after resident use, 2. failed to ensure that reusable equipment (blood pressure cuff/machine) was cleaned between use of residents, 3. failed to perform hand hygiene after removing gloves, and before preparing resident medications, 4. failed to put on gloves to dispense a powder stock medication (used bare hand to dispense), 5. Failed to remove a medication cup (not manufacturer provided) stored inside the stock powder medication. These failures applied to four (R5, R70, R79, and R129) of four residents reviewed during medication administration in the sample of 57 residents. Findings include: On 09/30/2025 at 08:14 AM V17 LPN (Licensed Practical Nurse) signed out each medication as administered after preparing the medication prior to them being administered to R70. 09/30/202508:16 AM, V17 knocked and entered R70's door. V17 moved R70's overbed table and adjusted R70's bed upright then administered her medications. On 09/30/2025…

    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 · D2024-10-03 · tag F0926 — failed to keep the home smoke-free / fire-safe — isolated
    Have policies on smoking.
    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 observations, interviews, and record review, the facility failed to implement their policy to adequately monitor residents during smoking times, ensure residents' turn over their smoking materials, and determine who is an active smoker for 2 (R6 and R81) of 3 residents reviewed for smoking in the sample of 48. Findings include: 1. R6 is a [AGE] year old female admitted to the facility on [DATE] with diagnosis including but not limited to Benign Neoplasm of Meninge, Cognitive Communicating Deficit, Dysphagia, Weakness, Chronic Viral Hepatitis C, and Encephalopathy. According to R6's MDS (Minimum Data Set) assessment dated [DATE], under section C, R6 has BIMS (Brief Interview of Mental Status) score of 13 indicating intact cognition. R6's care plan dated 11/20/2023 reads in part, (R6) is a smoker. Interventions: Instruct resident about the facility policy on smoking: locations, times, safety, concerns; Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. R6'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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-10 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident who required extensive assist with toileting was provided incontinent care in a timely manner for 2 or 4 residents (R2, R9) reviewed for Activities of Daily Living (ADL) in the sample of 13. The findings include: 1. R9's Physician Orders printed 5/5/24 showed her original admission to the facility was 4/19/24 with diagnoses to include: dementia, major depressive disorder, and diabetes. An Order dated 4/29/24 shows to turn and reposition every 2 hours and as needed. R9's Care Plan initiated on 4/30/24 shows she has an ADL deficit related to confusion, impaired balance, and limited mobility. She has a diagnosis of dementia and requires total assist with ADLs., is non ambulatory, and is incontinent of bowel and bladder. This care plans shows an intervention for bed mobility: the resident requires (extensive assist) by 2 staff to turn and reposition. An intervention for Personal Hygiene shows R9 is totally dependent on (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 · D2024-05-10 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to ensure a referral was made for a hearing aid request for 1 of 3 residents (R2) reviewed for resident rights in the sample of 13. The findings include: R2's facility assessment date 4/19/24 shows she has severe cognitive impairment, and is dependent on staff for Activites of Daily Living. This assessment shows R2 has minimal hearing difficulty. R2's physician order set printed 5/5/24 shows she has a diagnosis of dementia. R2's order set shows an order on 10/13/23 may have audiology evalation and May recieve the services of dentist/opthamologist, and audiologist PRN. On 5/4/24 at 2:28 PM, V33 (family member) said she had reported concerns to the director (V34). On 5/6/24 at 10:38AM, V34 (Liaison) said she is the liaison and does take resident and family complaints. V34 said she is usually the first one the family contacts, especially in the beginning. V34 said R2's family member contacted her on March 17, 20204, about concerns with Activity of Daily Living care and she reported those to the Director of Nursing (DON). V34 said…

    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 before2024-05-10 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure pressure relieving interventions were in place for a resident with a pressure injury, failed to ensure a pressure injury dressing was kept clean and intact, and failed to assess and implement treatment for a resident with a newly identified pressure injury for 2 of 3 residents (R3, R9) reviewed for pressure injury in the sample of 13. The findings include: 1. R9's Physician Orders printed 5/5/24 showed her original admission to the facility was 4/19/24 with diagnoses to include dementia, major depressive disorder, and diabetes. An Order dated 4/29/24 shows to turn and reposition every 2 hours and as needed, and offload heels while in bed every shift. A physician ordered dated 5/1/24 shows coccyx-clean with NSS [normal saline solution], apply medihoney, calcium alginate, cover with bordered dressing every 8 hours as needed for wound care if soiled or displaced. R9's record shows her weight on 4/29/24 was 129.2 pounds. R9's Care Plan…

    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 before2023-12-01 · 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 interview and record review, the facility failed to identify a vascular diabetic wound until it was necrotic for one of three residents (R2) reviewed for wounds in the sample of 12. Findings include: R2's electronic medical record show R2 was admitted to the facility on [DATE] with diagnoses that include dementia, diabetes and chronic kidney disease. On 12/1/23 at 10:22 AM, V20 (R2's son) said when R2 was still at the facility, he noted a large wound on R2's left foot by his heels that was black. V20 also said the time he was visiting R2, no staff was turning and repositioning R2. V20 said he had reported his concerns to the staff. R2's Wound Assessment detail report dated 9/27/23 show R2's Braden scale was high risk. Wound Information: -Facility Acquired, Vascular diabetic ulcer left heel. Purple ecchymosis (dark purple) 75% and necrotic 25% with bloody drainage. Wound measurement- 3.70 centimeters (cm) x 2.8 cm x 0.10 cm. R2's electronic treatment sheet dated 9/28/23 show left heel cleanse with normal…

    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 before2023-12-01 · 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 observation, interview, and record review, the facility failed to ensure fall interventions were in place for a resident who is at high risk for falls. This failure applied to one of three residents (R1) reviewed for safety in the sample of 12. Findings include: R1's face sheet shows she is [AGE] year-old female with diagnoses including metabolic encephalopathy, dementia, unspecified severity with agitation, major depressive disorder, scoliosis, unsteadiness on feet, repeated falls, muscle weakness and difficulty walking. R1's Final Incident Report dated 11/10/23 documents on 11/8/23 at 9:00 AM, (R1) sustained a fall from her bed resulting in a laceration over her right eye requiring skin glue. R1's CNA (Certified Nursing Assistant) was completing her morning activities of daily living and when she turned to get the wheelchair, (R1) fell out of her bed. (R1) was sent out to the local hospital and returned the same day, she sustained a laceration above the right eye with skin glue applied. R1's Minimum…

    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 before2023-12-01 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure that a resident was not housed in the same room as a resident that was placed on contact isolation to prevent the spread of infection for one of three residents (R5) reviewed for infection control in the sample of 12. Findings include: R5's Face Sheet shows diagnoses of: malignant neoplasm of the rectum, urinary retention and colostomy. R5's Urine Culture Report from 8/17/23 shows that he has no current infections. R4's Nursing Notes date 9/25/23 shows, Resident transported into the unit .from oncology appt (infusion visit) .(urinary) catheter still in placed .chemo implanted port remain intact .resident return from appt (appointment) with a scheduled f/u (follow up) oncology/infusion visit . R4 and R5's Census Reports show that they resided in the same room on 9/27/23. R4's Nursing Notes dated 9/27/23 shows, Discussed with nurse on duty new order for Macrobid (antibiotic) 100 mg (milligrams) BID (twice a day) x 7 days r/t (related to) E.Coli ESBL (Extended-spectrum beta-lactamases) and contact isolation. 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-20 · 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 follow their practice of identifying the name of the resident with the transportation company to ensure that the correct resident was sent to the correct appointment for one of three residents (R5) reviewed for right resident This failure resulted in R5 being dropped off at a non-dialysis clinic. R5 was subsequently taken to hospital for evaluation, Findings include: R5's face sheet shows R5 has diagnosis of hypertensive chronic kidney disease with stage 5 chronic kidney disease, type 2 diabetes with neuropathy, asthma, fluid overload, acute respiratory failure with hypoxia, pleural effusion, anemia, unspecified dementia, acute on chronic systolic heart failure, end stage renal disease, dependent on renal dialysis. MDS dated 7.28.23 denotes in-part BIMS score 10 (cognitive deficits). Section G for functional status denotes extensive assist and 1-person physical assist. R5 progress notes dated 8.24.23 completed by V2 (Director of Nursing) denotes in-part this writer was notified by the receptionist that the resident 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 · Dcited before2023-09-20 · 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 observations, interviews, and records reviewed the facility failed to implement fall prevention interventions for two residents at high risk for falls. This failure affected two of three residents (R2 and R9) reviewed for fall prevention interventions The findings include: 1. R2's diagnosis include but are not limited to Amyotrophic Lateral Sclerosis, Weakness, and Osteoarthritis. On 9/14/23 at 11:29 AM, V9, Certified Nursing Assistant (CNA), said R2 was at risk for falls. On 9/14/23 at 3:15 PM, V10, Registered Nurse, said on 9/5/23 I observed R2 sitting on the floor. V10 said R2 had been sitting in a chair in his room and I believe he was trying to get his walker. V10 said I didn't know if R2 had fallen before. V10 said R2 had been walking independently with a walker and he was working with physical therapy. On 9/15/23 at 9:26 AM, V2, Director of Nursing, said R2 was admitted with a history of falls. V2 said R2 had a fall on 8/12/23. V2 said R2 had lost his balance on 8/12/23 and he was not using a…

    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 · D2023-07-14 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    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 assessment to determine safe self-administration for one of one resident (R95) reviewed for self-administration of medication in a sample of 26. Findings include: On 07/11/2023 at 10:58 AM, during observation rounds, R95 was observed lying on the bed with bedside table in front of him. Bedside table was observed with R95's Fluticasone Furoate/Vilanterol Inhaler 100/25 micrograms (mcg)/inhalation (inh) and R78's Fluticasone proprionate 50 mcg/actuation (act). On 07/12/2023 at 10:31AM during observation with V23 (Registered Nurse), R95's Fluticasone Furoate/Vilanterol Inhaler 100/25 micrograms (mcg) and R78's Fluticasone proprionate 50 mcg/actuation (act) was again observed at the bedside table. On 07/12/2023 at 10:31AM, V23 removed the medications and stated that it should not be there. On 07/12/2023 at 11:02 AM, V2 (Director of Nursing) stated that if the resident gets anxious and prefers to have their inhalers at bedside, they obtain an order from the physician and leave it at the bedside. She said…

    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 · D2023-07-14 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to follow its policy in displaying prominently in the medical record whether a resident has executed an advance directive for one resident (R2) reviewed for code status in a sample of 26 residents. Findings include: During record review on 7/12/23 at 10:30 am, R2's electronic record was noted with no code status. The DNR (Do Not Resuscitate) binder and R2's chart was also not with no code status for R2. On 7/12/23 at 11:30 am. V2 (Director of Nursing) stated that the code should be in the resident's record. V2 also stated that the code status can be found in the DNR binder and patient's chart. V2 updated the medical record during the interview process. On 7/12/23 at 1:00 pm, both V29 (RN) and V30 (LPN) both stated that the code status should be in the resident's chart, binder or in the computer. Facility policy titled Advance Directive revised 11/2020 reads; Policy Statement: Advance directive will be respected in accordance with the state law and facility policy. Policy Interpretation and Implementation. 7. information about…

    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 · D2023-07-14 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to comprehensively assess at the time of the required comprehensive assessment for one of six residents (R9) reviewed for resident assessment in a sample of 26. Findings include: On 07/11/2023 at 11:37 AM during observation rounds, R9 was observed sitting on bed and stated that she feels like she is losing weight and has never met the dietitian. On 07/13/2023 at 2:05 PM, V22 (MDS [Minimum Data Set] Coordinator) said that all comprehensive assessments are usually done between 3-5 days before the assessment date. On 07/14/2023 at 10:20 AM, V25 (Registered Dietitian) said that she tries to within the 7 days before and after the assessment date, comprehensive assessment is done on residents. V25 reviewed R9's electronic health record and stated that she should have an assessment for 5/3/2023. R9's Order Summary Report dated 7/13/2023 indicated admission date of 4/29/2022, and diagnoses including iron deficiency anemia unspecified and anxiety disorder unspecified. Dietary Progress Notes from 08/11/2022 to 7/12/2023 were reviewed…

    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 · D2023-07-14 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    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 observation, interview, and record review the facility failed to provide ongoing assessment and revise care plan for a resident who has hearing impairment. This deficiency affects one (R8) of one resident in the sample of 26 reviewed for Sensory impairment. Findings include: On 7/11/23 at 11:30 am, R8 is alert and oriented, able to verbalize needs to staff but because R8 is hard of hearing, he requires speakers to adjust their tone and volume and speak distinctly to be heard and understood. He said that he has had hearing problems for a while. He said he went to audiologist last month and failed the test. He said that he is scheduled for follow up appointment soon for possible hearing aid device. He said that he has been in the facility for 7 months. On 7/12/23 at 1:28 pm, V1 Administrator said that R8 is the one making his own medical appointment and will inform the nurse for his transportation arrangement. She said that they don't have copy of his medical record from his audiologist. They will call R8'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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-14 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    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 its Providers Orders for Infusion Therapy policy by not obtaining intravenous flush orders at the time intravenous medication is ordered. This failure effects 1 of 2 residents (R112) reviewed for Intravenous administration in a sample of 26. Findings Include: On 7/11/2023 at 12:00 pm, V20 (Nurse) was observed flushing intravenously, 10 milliliters of normal saline, administering R112 intravenous antibiotic therapy, flushing with 10 milliliters of normal saline in the left antecubital by (peripherally inserted central catheter-PICC) line. R112 did not have an order for intravenous flushes. V20 said I thought it was an order for flushing. On 7/11/2023 at 1:00 pm, V3 (Assistant Director of Nursing - ADON) said the intravenous flush orders should be obtained when the antibiotic orders where given. An Order Summary Report dated 7/7/2023 indicates R112 has an order for Piperacillin Sodium-Tazobactam Solution Reconstituted with 3.375 grams intravenously every six hours for urinary tract infection for 7 days.…

    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 · D2023-07-14 · tag F0660 — isolated
    Plan the resident's discharge to meet the resident's goals and needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record reviewed, the facility failed to follow its policy in developing a post-discharge plan with the resident's family for one resident (R130) reviewed for discharge planning in a sample of 26 residents. Finding include. During review of closed records on 7/13/23 at 1:30 pm, R130's progress note was noted to still have R130 as out on pass. On 7/13/23 at 2:15 pm, V8 (Social Service Director) stated that R130 went out on a pass with family and decided not to return to the facility. V8 updated the resident's chart after surveyor made V8 aware during the interview. On 7/13/23 at 12:45 pm, V22 (MDS Coordinator) unable to be reached. Nursing notes dated 4/10/23 at 7:41 am, reads; Resident noted out on pass with family, writer spoke with resident sister and stated resident would like to stay overnight and will return in AM, nursing supervisor made aware. Facility policy dated 11/2020 reads: Discharge Summary and Plan. Policy statement: When a resident discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to…

    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 · Dcited before2023-07-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation interview and record review the facility failed to ensure residents who were dependent on staff for shaving and fingernail care received those services for 1 of 5 residents (R112) reviewed for (Activities of Daily Living- ADL) assistance in a sample of 26. Findings include: On 7/11/2023 at 11:30 am, V19 (Certified Nursing Assistant-CNA) observed with writer R112 face unshaved and fingernails long. V20 said R112 should be shaved and fingernails should be cut down. On 7/11/2023 at 12:00 pm, V20 observed with writer R112 face unshaved and fingernails long. V20 said R112 should be shaved and his fingernails should be cut down. On 7/11/2023 at 1:00 pm, V3 (Assistant Director of Nursing-ADON) observed with writer R112 face unshaved and fingernails long. V3 said R112 should not look like this and said he should be shaved and his fingernails should be cut down. A care plan dated 11/2/2022 indicates that R112 has focus of ADL self-care performance deficit related to diagnosis of Dementia, right above the knee amputation, and hypertension. An intervention of 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
  • Potential for harm · Dcited before2023-07-14 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to follow orders per their Order Summary Report to off load heels while in bed. This failure effects 1 of 8 residents (R112) reviewed for prevention of pressure ulcers in a sample of 26. Findings include: On 7/11/2023 at 11:30 am, R112 was observed with V19 (Certified Nursing Assistant-CNA) with his left heel laying on the bed, V19 said I don't know if R112 foot should be elevated on pillows or not. On 7/11/2023 at 12:00 pm, V20 (Nurse) said R112 left heel should be elevated on pillows to prevent any skin breakdown. On 7/11/2023 at 1:00 pm, V3 (Assistant Director of Nursing-ADON) observed R112 left heel laying on the bed and said his left heel should be off loaded while in bed to try and prevent a pressure ulcer. On 7/13/2023 at 8:00 am, R112's left heel was observed laying on the bed. R112 said the pillow was there only one day. An Order Summary Report dated 7/14/2023 indicated that R112 has an order to off load heels while in bed every shift prescribed on 12/20/2022. Facility Policy: 1/20/2019 Prevention of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-14 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide range of motion (ROM) exercises to one resident (R34) out of eight residents reviewed for ROM in a sample of 26. Finding includes: On 07/11/23 11:34 AM, R34 was observed in her room with V10 (RN). R34 has bilateral hand contractures with no split on. V10 reviewed both R34 physician order and care plan; no split was ordered. V10 said that R34 should have a splint to prevent further contractures. On 7/12/2023 at 10:30 am, V8 (Physical Therapy Director) said that R34 was discharged from occupational therapy and referred to restorative program on 5/25/2023 while awaiting for bilateral hand splints. V8 said that restorative nurse should have carried out the recommendation of ROM from Occupational therapy. On 7/12/2023 at 10:35 am, review of care plan with V2 (DON/Restorative Nurse) and V8 did not indicate that R34 should be on bilateral progressive hand splints. Rather, the care plan indicated that R34 wears right hand splint daily 6-7…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2025-12-19 · tag F0580 — failed to tell family and doctor about changes — widespread
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review, the facility failed to follow its room-to-room transfer policy for R1 by not notifying R1's power of attorney of a room change for one of three resident's review for transfers. Findings Include:On 12/18/25 at 11:27am, V3 (Social Service Director) said, we did not notify V11 (R1's Power of Attorney) for R1 room transfer on 9/16/25.R1 power of attorney paperwork dated 8/22/25 documents: V11. R1's electronic record did not document any notification on 9/16/25.Room to room transfer policy dated 4/2014 documents: Prior to the room transfer, the resident, his or her roommate (if any), and the resident's representative (sponsor) will be provided with information concerning the decision to make the room transfer.

    Resident Rights Deficiencies · No revisit needed

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to PAVILION HEALTHCARE — 5 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 53.0≈ chain avg
Health inspection 3 of 53.0≈ chain avg
Staffing 2 of 52.0≈ chain avg
Quality measures 3 of 53.4-0.4 vs chain
The other 4 homes this chain runs (chain average 3.0★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
ILANA D AARON TRUST C/U MAURICE AARON 2014 FAMILY GIFT TRUSTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST12%since 12/19/2022
ILANA D AARON TRUST C/U MAURICE AARON 2014 LEGACY GIFT TRUSTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST9%since 12/19/2022
STERN, TODDIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST6%since 12/19/2022
GRAF, MARCELLAIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 12/19/2022

CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

2 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.

$16.3M
Net patient revenuemost recent cost report
-1.5%
Operating marginrevenue minus expenses
$2.9M
Related-party expense17% of expenses
Who pays — share of resident-days
Medicaid 26%Medicare 16%Other / private 58%

This home reported $2.9M paid to related parties — landlords or management companies under common ownership — equal to about 17% 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

$341per resident / day
operating cost
$10,353per month
≈ monthly operating cost
$336per 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 145208. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-04, 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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