Thryve of Burbank

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

57.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 54 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 50.0% 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 22 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 0.09 therapist hours per resident per day in 2026Q1 — more than 5% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 163 beds and averages 112.8 residents a day — about 69% occupied, or roughly 50 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.18 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.68 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.74 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 2.73 hrs/resident/day on weekends vs 3.36 on weekdays — 19% thinner on weekends. RN hours go from 0.76 to 0.47 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 37% is about the same as the national median of 45%.

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

Inspection trend

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

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.

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.

49 citations, most serious first. The 18 most serious are shown; the remaining 31 are one tap away and print in full.

• Actual harm · Gcited before2026-01-11 · 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 ensure residents received adequate supervision and assistance during care in accordance with their assessed needs and care plans. This failure applied to two (R1 and R2) of three residents reviewed for accidents. These failures resulted in falls while being provided care that required emergent hospital transfer. R2 required three staples for the laceration to the left scalp and R2 also had a left shoulder contusion. Findings include: R1 is an [AGE] year-old resident admitted to the facility on [DATE] with the diagnoses, including but not limited to morbid obesity, lack of coordination, chronic obstructive pulmonary disease, dementia, and hypertension. The facility reported incident documents that on [DATE], a resident slid on the floor during care. EMS (Emergency Medical System) was notified. The resident later became unresponsive. CPR (Cardiopulmonary Resuscitation) was initiated. The facility is awaiting the coroner's report. Minimum Data Set (MDS)…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-03-28 · 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 develop and implement effective safety interventions, including frequent monitoring, for two dependent, immobile, ventilator-dependent residents at high risk for falls to prevent them from falling out of bed. This failure affected two of three residents (R1 and R3) reviewed for accidents and safety. As a result, R1 fell from the bed and sustained a C2 fracture. Findings include: 1.) R1's diagnosis include but are not limited to Anoxic Brain Damage, Respiratory Failure, Tracheostomy, Gastrostomy, Dependence on Respiratory [Ventilator] Status. A new diagnosis of Displaced Fracture of Second Cervical Vertebra dated 3/12/25. R1's cognitive assessment date 2/1/25 identifies she is severely impaired. R1's functional ability assessment dated [DATE] indicates R1 has impaired in range of motion to upper and lower extremities. Additionally, R1 is identified to be dependent on staff for all Activities of Daily Living. Section O identifies R1 has 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
• Actual harm · G2024-05-23 · tag F0580 — failed to tell family and doctor about changes — isolated
  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 — 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 notify the physician of a resident not having any urine output from the urinary catheter for an entire eight-hour shift. This affected one of three residents (R2) reviewed for physician notification in a total sample of six. This failure resulted in R2 retaining 1,450 mL (milliliters) of urine in the bladder (maximum capacity is [PHONE NUMBER] mL) and needing to be treated for a urinary tract infection and an acute kidney injury at the hospital. Findings Include: R2 is a [AGE] year-old with the following diagnosis: quadriplegia, neuromuscular dysfunction of the bladder, dysphagia, and encounter for gastrostomy. A Nursing note dated 5/18/24 documents R2 refused breakfast and lunch. R2 reported not feeling well vital signs were stable. A Nursing note dated 5/19/24 documents a physician was not notified at 12:57 PM that the urinary catheter was leaking and R2 was exhibiting confusion. A Physician note dated 5/19/24 documents the nurse reported vital signs…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-05-23 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess, change, or flush a resident's urinary catheter after the resident did not have any urine output from the catheter for an entire eight-hour shift. This affected one of three residents (R2) reviewed for catheter care in a total sample of six. This failure resulted in R2 retaining 1,450 mL (milliliters) of urine in the bladder (maximum capacity is [PHONE NUMBER] mL) and needing to be treated for a urinary tract infection and an acute kidney injury at the hospital. Findings Include: R2 is a [AGE] year-old with the following diagnosis: quadriplegia, neuromuscular dysfunction of the bladder, dysphagia, and encounter for gastrostomy. A Nursing note dated 5/18/24 documents R2 refused breakfast and lunch. R2 reported not feeling well vital signs were stable. A Nursing note dated 5/19/24 documents a physician was not notified at 12:57 PM that the urinary catheter was leaking and R2 was exhibiting confusion. A Physician note dated 5/19/24 documents the…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-04-26 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to identify, assess, and treat a post-surgical wound site for 1 of 3 residents (R1) reviewed for wounds in the sample of 9. This failure resulted in R1's wound site becoming infected, requiring a 10-day course of antibiotics, and at least four weeks of wound care treatment. The findings include: R1's Face Sheet printed 4/26/24 shows she was admitted to the facility on [DATE]. R1's Nurse Practitioner's (NP) Progress Notes dated 2/8/24 at 9:51 AM show R1 is status post tracheostomy and PEG (feeding) tube placement on 1/31/24. R1's Progress Notes show the Wound Care Nurse's, V4, note dated 2/8/24 at 2:16 PM shows R1's admission skin assessment was complete. No wound to R1's right clavicle/neck was documented. On 2/20/24 at 5:28 PM, Respiratory Therapy documentation shows redness was noted on R1's right side next to her stoma (tracheostomy) site with an embedded suture in the skin. Nursing notes dated 2/20/24 at 7:33 PM show R1 has a wound to her right front…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-11-28 · 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 implement interventions to monitor a resident with cognitive deficits and impulsive behaviors and failed to utilize assist of two people for bed mobility and repositioning. This affected 3 of 6 (R9, R10, and R16) residents reviewed for safety and fall prevention. This failure resulted in R16 falling, sustaining a laceration requiring 6 staples and having an acute fracture of left proximal humeral with displacement. R10 slid out of bed and developed an open and raised area on her forehead. The findings include: 1.R16 is [AGE] years old with diagnosis including but not limited to Dementia with Behavioral Disturbances, Major Depressive Disorder, Osteoarthritis, Insomnia, History of Left Arm Humerus Fracture, Palliative Care, Cognitive Communication Deficit, Difficulty in Walking, Need for Assistance with Personal Care, History of Falling, and Weakness. On 11/14/23 at 11:45AM V18 (Licensed Practical Nurse/LPN), said I saw R16 sitting in the edge of the bed…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-06-29 · 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 A. Based on interview and record review, the facility failed to acknowledge and transcribe hospice orders that were provided for one resident (R299) at the start of hospice care. This failure affected one out of four residents reviewed for receiving hospice care in the facility and led to R299 receiving a hemodialysis treatment after the order for hemodialysis was discontinued; placing R299 at increased risk of hemodynamic instability. This failure led to R299 expiring during hemodialysis treatment. Findings include: R299 was a [AGE] year old female who was admitted to the facility [DATE] with diagnoses that included Hypertensive heart and End Stage Renal disease. On [DATE] at 12:57PM, V46 Family member said, [R299] came in [to the facility] for a minor stroke and was getting therapy. We (the family) realized she was declining and unable to tolerate the dialysis. They kept trying to dialyze her and she didn't have any fluid to take away, she was so small. We discontinued dialysis and put her on hospice on 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
• Actual harm · Gcited before2023-06-29 · 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 record reviews the facility failed to follow their policy and procedures to prevent falls by not ensuring fall risk assessments were performed quarterly to reassess residents fall intervention needs, failed to not ensure a resident was adequately supervised; failed to not ensure a quadriplegic resident with a history of falling out of bed with two staff providing care received two person assistance when receiving incontinence care; and failed to ensure safety practices were applied for this resident when beginning to fall out of bed. These failures resulted in R28 experiencing a fall and sustaining a head injury and resulted in R58 falling out of bed and sustaining a right leg fracture. The facility failed to provide a resident with needed assistance and the resident subsequently had two falls within an hour time period. This failure applied to one (R45) of one resident reviewed for falls. Findings include: R28 is a [AGE] year-old female with a diagnoses history 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 · Fcited before2026-04-16 · tag F0880 — failed to prevent and control infections — widespread
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure unused isolation gowns were not hanging inside the sorting area of the soiled linen room and failed to ensure contaminated material did not cross over the clean area in the laundry room in an effort to prevent spread of infection. These failures affected 2 (R6 and R7) residents reviewed for infection control and have the potential to affect all the 123 residents at the facility. Findings include:The (04/13/20260 midnight census report documented that there were 123 residents at the facility. On 04/13/2026 at 12:23pm by the Laundry's Soiled Linen room, there were 2 yellow isolation gowns hung by the sorting area. On 04/13/2026 at 12:28pm by the dryers inside the laundry's clean area, there was a paper stuck between the drum and the door of the 2 dryers; one paper contained R6's name and room number, and the other paper contained R7's name and room number. V6 (Laundry Aide) stated she got the paper from the resident soiled linen clothing and stuck them between the drum and the door of the dryer so she…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-01-23 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  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

  Based on observation, interview, and record review, the facility failed to follow their Extreme Weather Temperature Policy by not maintaining indoor temperatures in the range of 71 degrees to 81 degrees Fahrenheit. This failure affected 3 residents (R8, R9, R11) in dialysis and 4 residents (R6, R7, R12, R13) residing on the wing complex.On 1/20/2026 at 11:50AM, during unit rounds, state agency observed residents in the XXX complex unit hallway wearing multiple layers of clothing, hoodies, zipped up jackets. State agency and V3 (Assistant Director of Nursing/ADON) continued walking down the hallway of the XXX complex wing and observed V3 zipping up her blue sweater. V3 stated this hallway is cold. State agency observed multiple staff wearing zipped up sweaters.On 1/20/2026 PM at 12:03PM, V9 (Maintenance Director) stated the complex XXX wing heater system was down and the facility called a company to come and assess the heating system in the end of November. V9 stated after the company came and worked on the heating issue, it resolved the heating issue to the rooms on the left side 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-01-23 · 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 follow their Fall Guideline Policy when the admitting nurse failed to complete the Fall Risk Evaluation upon a resident's admission into the facility. This affected 1 (R1) resident of 3 reviewed for accidents.R1 is a [AGE] year-old female admitted to the facility on facility 6/5/2025 at 12:30PM and discharged date on 6/6/2025 at 3:36PM. R1's medical diagnosis are, but are not limited to, Chronic Obstructive Pulmonary Disease with acute exacerbation, acute respiratory failure with hypercapnia, type 2 diabetes mellitus, unspecified asthma with acute exacerbation, epilepsy with status epilepticus, chronic fatigue, history of falling, lack of coordination, altered mental status, abnormal electroencephalogram, other supraventricular tachycardia, hypertension.On 1/21/2026 at 11:11 AM, V16 (Restorative Director) stated the fall assessment evaluation for new admitting residents should be done on admission by the admitting nurse. V16 states that I…

  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 before2025-09-03 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  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 their employee handbook on cell phone usage by having a staff member take a personal phone call while providing care to a resident. This failure affected 1 (R1) of 3 residents reviewed for resident rights in a total sample of 6. Findings include:R1 is a [AGE] year-old male originally admitted on [DATE] with medical diagnosis that include and are not limited to: paraplegia, diabetes mellitus type 2, convulsions, hypertension, unspecified injury at unspecified level of cervical spinal cord, and colostomy status. Per the Minimum Data Set (MDS) dated [DATE], reads: Brief Interview for Mental Status score 15/15, cognitively intact.On 9/2/2025 at 11:17 AM, R1 stated an incident occurred on Thursday, 8/28/25 around 4:00 PM. R1 stated during R1's shower on the shower bed by the nurse's station shower room a Certified Nursing Assistant (CNA) was using her cell phone, using face time during R1's shower. R1 cannot provided the name 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-06-25 · tag F0908 — failed to keep essential equipment working — widespread
  Keep all essential equipment working 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 upon observation, interview, and record review the facility failed to follow policy procedures, failed to maintain the chiller (air conditioner), failed to clean intake vents, failed to document equipment maintenance, and failed to ensure that the chiller was functioning properly. These failures affected 108 residents residing in the facility. Findings include: The (6/17/25) census includes 108 residents. On 6/17/25 at 9:21am, V3 (Maintenance Director) stated right now I'm (V3) having an issue with the chiller, which is brand new, it was installed last year. There's dirt and debris in there so I (V3) was up on the roof trying to flush it out. When there's dirt that builds up, it will throw a low water flow diagnosis so basically if the waters not at a certain flow it will throw that code and shut the unit down. Surveyor inquired if the chiller was currently shut down. V3 replied Right now yes because I was cleaning it. On 6/17/25 at 10:48am, V5 (Maintenance) stated The chiller is having low water flow…

  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 before2025-01-12 · 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 implement fall prevention interventions for a resident identified at risk for falls for one (R1) out of three residents reviewed for accidents in a total sample of three residents. Findings include: R1's face sheet documents that R1 is a [AGE] year-old individual with diagnoses not limited to: respiratory failure, dysphagia, oropharyngeal phase, cognitive communication deficit, other reduced mobility, anxiety disorder, unspecified. R1's face sheet documents in part R1 was initially admitted to the facility on [DATE] and discharged from the facility to the hospital on [DATE]. On 01/11/2025, at 11:44 AM, V7 (Licensed Practical Nurse) states that nurses work 12-hour shift. V7 states that she cannot recall who was the CNA (certified nursing assistant) working with her the date that R1 fell from her bed. V7 states that she floats. V7 reports that she remembers before leaving off the unit, she did her last round, and V7 states that she saw R1 lying in bed. V7…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-08-30 · tag F0607 — failed to have anti-abuse policies — pattern
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement the written policy and procedure that prohibit and prevent abuse. This deficiency affects all four (R46, R66, R106 and R107) residents in the sample of 23 reviewed for Abuse prevention Program. Findings include: On 8/28/24 at 12:35PM, V9 (Social Service Director/SSD) that they have four identified offender residents in the facility. Review medical records of R46, R66, R106 and R107. Noted that they don't have care plan developed as an identified offender in their charts. V9 said that she does not develop care plan for identified offender residents. She added that she is not aware that she must develop for them. Reviewed facility's identified offender policy with V9 indicates that care plan should incorporate resident who is identified offender including security measures. On 8/28/24 at 2:26PM, Informed V1 (Administrator) of above concern. V1 said that he will talk to V9 (SSD). Review R106's medical records. Unable to locate…

  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 · Ecited before2024-08-30 · 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 implement its fall preventive interventions for a resident who is at high risk for falls. The facility failed to implement its policy on investigating and reporting resident's incident. The facility failed to assess accurately a resident who smokes in the facility. This deficiency affects all four (R6, R7, R103 and R106) residents in the sample of 23 reviewed for Resident safety. Findings include: 1. On 8/27/24 at 11:58AM, Observed R7 lying in bed, on semi-Fowlers position. She has oxygen via nasal cannula. Her bed is in high position. She has folded floor mat on side of the wall - one closer to the window side and the other one closer to the bathroom side. V12 (Licensed Practical Nurse/LPN) said, she is not sure if R7 is on fall precaution, but she is sure of R6 (the roommate). On 8/27/24 at 12:05PM, Observed R6 lying in bed with floor mat only on the right side of the bed (by the window side). The bed is on high position. V12 (LPN) took…

  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 before2024-08-30 · 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 implement their appropriate extreme high temperature policy and procedures in the facility. This deficiency affects two (R103 and R69) of three residents in the sample of 23 reviewed for Safe and comfortable resident environment. Findings include: 1. On 8/27/24 at 11:54AM, Rounds were made to the 2nd floor unit. Surveyor felt warm air on the unit and noted two electric fans by the nursing station; there was no electric fan by the unit hallway. On 8/27/24 at 12:18PM, Observed R103 sitting in a wheelchair, wearing a gown and a brief. R103 complained that he cannot sleep because his room is hot. He said he feels exhausted. He was observed trying to remove his gown and appears restless. R103 keeps saying the room is hot. The window curtain was observed open with sunlight going through the window and into his room. The air conditioner was located by the window with warm air coming out. Showed observation to both V12 (Licensed Practical…

  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 · D2024-08-30 · 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 follow the facility's policy for using Low Air loss mattress regarding bed linens for a resident with skin impairment. This deficiency affects one (R7) of three residents in the sample of 23 reviewed for Prevention of Pressure wounds protocol. Findings include: On 8/27/24 at 11:58AM, Observed R7 lying in bed with low air loss (LAL) mattress. V12 (Licensed Practical Nurse/LPN) said that R7 has pressure ulcer and on wound care management. Checked bedding with V12 and V2 (Director of Nursing/DON). Observed multi-layers of linen. R7 has folded linen in quarters used as draw sheet and cloth pad over the LAL mattress. R7 wears disposable adult brief. V2 (DON) said that resident on LAL mattress should only be on a flat sheet over the LAL mattress. V2 instructed V12 (LPN) to inform the CNA (Certified Nursing Assistant) to remove the folded linens and cloth pad underneath R7. On 8/28/24 at 11:38AM, V11 (Wound Care Nurse) said that resident on LAL…

  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.

Fines & penalties

$54,208 in federal fines across 3 penalties. 1 Medicare payment denial on record.

• $10,097 — penalty dated 2024-05-23
• $15,725 — penalty dated 2024-04-19
• $28,386 — penalty dated 2023-11-28
• Medicare payment denial — starting 2026-01-30 for 11 days

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

Part of a chain

This home belongs to ALIYA HEALTHCARE — 14 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 →

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

CMS files one row per role, so the 9 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

4 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.

About 91% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.4M 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

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

What families pay in IL