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Eden Vista Burr Ridge

6801 Highgrove Boulevard, Burr Ridge, IL 60527 · For profit - Limited Liability company · 29 certified beds · (630) 920-2900 Medicare only — no Medicaid

Call the home — (630) 920-2900 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited May 2026Behavioral-health or dementia-care citation — no harm found (F0758)3 actual-harm citations
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 3 actual-harm citations
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • nursing-staff turnover (70%) runs well above the national median (45%)

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

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

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

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
545 Plainfield Rd Ste E · (630) 269-2886 · Call to confirm hours
Pharmacy
501 Plainfield Rd · (630) 789-1797 · Call to confirm hours
Grocery
840 Plainfield Rd · (630) 332-8200 · Call to confirm hours
Park
Waterford Park, 6620 Rodgers Dr · 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 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents who lose too much weight4.8%6.3%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.9%0.9%better
Long-stay residents with a urinary tract infection0.0%1.5%2.0%better
Long-stay residents with depressive symptoms12.5%54.2%6.5%better 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 injury0.0%3.1%3.3%check this — see note marked star below the table
Long-stay residents on antianxiety or hypnotic medication27.3%18.3%18.9%worse
Long-stay residents with pressure ulcers3.6%4.8%4.7%better
Long-stay residents with worsening bladder/bowel control27.2%20.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table25.0%21.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication4.3%2.2%1.4%worse
Short-stay residents given the seasonal flu vaccine71.2%63.1%79.4%worse
Short-stay residents rehospitalized after admission34.9%26.1%22.6%worse
Short-stay residents with an outpatient ER visit6.4%13.9%12.0%better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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.

48.5% 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 189 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

48.5%U.S. median 51.5%
Got home and stayed home
11.4%U.S. median 10.7%
Went back to hospital
66.7%U.S. median 56.6%
Met the expected recovery
1.17U.S. median 0.31
Therapy hours / resident / day
0.53hours / resident / day
Physical therapy
0.53hours / resident / day
Occupational therapy
0.11hours / resident / day
Speech therapy

Met the expected recovery: 66.7% 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 45 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 1.17 therapist hours per resident per day in 2026Q1 — more than 98% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 21% 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 SNF48.5%CMS range 39.0–55.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.4%CMS range 8.3–14.210.7%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 discharge66.7%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 discharge68.9%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 discharge60.0%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 identified97.2%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 discharge97.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%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 hospitalization6.4%CMS range 3.6–10.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.981.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

1.61
RN hours/ resident / day
0.54
LPN hours/ resident / day
2.55
Aide hours/ resident / day
4.69
Total nurse hours/ resident / day
1.38
RN hoursweekends
70.0%
Total nursing turnover
76.9%
RN turnover

How full it usually is: this home is certified for 29 beds and averages 21.2 residents a day — about 73% occupied, or roughly 8 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.69 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.61 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.55 is at or above 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 4.11 hrs/resident/day on weekends vs 4.92 on weekdays — 16% thinner on weekends. RN hours go from 1.70 to 1.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 70% is well above the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

5
deficiencies at the latest standard inspection (2025-12-31)
8
at the previous standard inspection (2025-01-30)

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

Inspection deficiencies

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

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.

24 citations, most serious first. The 13 most serious are shown; the remaining 11 are one tap away and print in full.

  • Actual harm · Gcited before2026-07-02 · 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

    Based on interviews and record review, the facility failed to follow its fall prevention policy and provide adequate supervision for one cognitively impaired resident who was identified as being at high risk for falls. This affected one of three residents (R1) reviewed for fall prevention. This failure resulted in R1 having two unwitnessed, avoidable falls occurring on the same day, following the second fall R1 was transported to the hospital, where the resident was diagnosed with a spinal compression fracture.Findings include:On 6/30/26 at 1:21 PM, V4's RN (registered nurse) stated that R1 had an unwitnessed fall on the hallway floor on the morning of 5/25/26. V4 stated that R1 was confused, at baseline. V4 stated that at the time of R1's fall, V4 and CNAs (certified nurse aides) were in other residents' rooms providing care. V4 stated that R1was able to self-propel in wheelchair. R1 was assessed, no injuries noted. V4 stated that R1's vital signs were stable, and neurological checks were ordered due to it being an unwitnessed fall. V4 stated that neurological checks are documented…

    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 plan of correction
  • Actual harm · Gcited before2026-05-21 · 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 provide adequate supervision and safe transport technique and failed to implement care plan interventions to prevent an accident for a resident (R1). The facility failed to follow facility fall prevention policy, failed to develop and implement care plan interventions to prevent recurrent falls, and failed to complete post fall assessment for one of three residents (R2), reviewed for falls. These failures resulted in R1 falling and sustaining a closed head injury, abrasion of the forehead, avulsion of right elbow skin, and a closed nasal bone fracture, and R2 sustaining seven falls within sixteen days, hospitalization, scalp laceration requiring sutures, and a subdural hemorrhage. Findings include:R1 is an [AGE] year old resident with latest admission to the facility on 3/24/26. R1 has diagnoses which include but are not limited to Polyneuropathy and Generalized Anxiety disorder.R1's Records show the following:Fall Risk assessment dated…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has plan of correction
  • Actual harm · G2024-04-19 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that medications were present for a resident with recurrent diarrhea and to notify the Physician about the medications, failed to ensure lab testing was completed in a timely manner for the resident, and failed to ensure staff responded to the resident's stool incontinence in a timely manner. These delays in treatment resulted the addition of a third medication, and the resident experiencing increased weakness and skin irritation. This applies to 1 of 4 residents (R14) reviewed for nursing cares in a sample of 26. Findings include: R14 was admitted to the facility on [DATE]. R 14 has diagnoses that includes congestive heart failure, muscle weakness, and enterocolitis due to clostridium difficile. R114's MDS (Minimum Data Set) shows he is cognitively intact and requires staff assistance for mobility using a walker. R14's care plan dated 2/11/24 includes actual impaired skin integrity, MASD (Moisture-Associated Skin Damage) 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-21 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review facility failed to initially report a severe injury of unknown origin to the Illinois Department of Public Health (IDPH) no later than two hours after the incident for one resident (R2) of eight residents in the sample. This injury resulted in R2 being hospitalized for scalp laceration requiring sutures, and a subdural hemorrhage. Findings include: On 4/19/2026 at 5:00 AM V13 (Registered Nurse) documented in the risk management/incident report V13 (Nurse) was informed by Certified Nursing Assistant (CNA) R2 had blood on R2's bed. Upon assessment a small laceration was noted to the right top of R2's head. R2 was unable to recall what happened. Incident was unwitnessed. R2 was transferred to the hospital for head injury. On 4/19/2026 at 6:24 AM V13 (Nurse) documented in the electronic health record (EHR) V13 was informed by CNA that R2 was noted with dried blood on linens and floor near bed. Upon assessment, R2 was observed with a 1-inch laceration to right top of head. R2 complained of pain to right hip and sacral area. Physician notified with…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · Ecited before2025-12-31 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    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 assist residents identified as needing assistance with personal hygiene and grooming.This applies to 4 of 4 residents (R7, R9, R10 and R16) reviewed for ADL (activities of daily living) in the sample of 12.The findings include:1. R10 has multiple diagnoses including, unspecified dementia without behavioral disturbance, based on the face sheet. R10's admission MDS (minimum data set) dated November 13, 2025 showed that the resident was severely impaired with cognition and required total assistance from the staff with most of her ADLs including upper body dressing and personal hygiene. On December 28, 2025 at 11:18 AM, R10 was in her wheelchair inside the dining room. R10 was alert and was able to respond appropriately to simple questions. R10 had long curling facial hair above her lips mostly on the right side, her fingernails were uneven (some were long and some were short), some were jagged with chipped red nail polish and under her…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-31 · tag F0805 — failed to prepare food in a form residents can eat — pattern
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide mechanically altered food consistency for residents prescribed the level 6 soft and bite sized diet. This applies to 4 of 4 residents (R1, R16, R19, R30) reviewed for altered consistency diets in the sample of 12. The findings include:The Facility's diet type report dated December 29, 2025, showed R1, R16, R19, and R30 were prescribed the #6 soft and bite sized diet. R1's face sheet showed R1 was [AGE] years old, admitted to the facility on [DATE], and had multiple diagnoses including sepsis, protein calorie malnutrition, vascular dementia, presence of gastrostomy tube, Dysphagia, pharyngeal phase, and type 2 diabetes.R1's physician order showed Regular diet, Level 6 Soft & Bite Sized texture, Level 0 Thin (Regular) consistency initiated on December 16, 2025. R1's Speech Therapy recommendations dated December 5, 2025, showed to initiate po (oral) diet of mechanical soft/thin using small bites/sips and slow rate. R1's therapy…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-12-31 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    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 standard infection control practices related to hand hygiene and gloving during provisions of incontinence care and administration of medication. The facility also failed to ensure that staff would wear complete PPE (personal protective equipment) during provision of care for residents who are on EBP (Enhance Barrier Precaution). This applies to 5 of 12 residents (R2, R3, R7, R10, R18) reviewed for infection control in the sample of 12. The findings include: 1. On December 29, 2025, at 10:23 AM, V5 (Nurse) administered multiple medications to R10. When R10 showed sign that she was having difficulty swallowing her medications, V5 took the CO Q10 capsule and Acidophilus capsule of R10, without hand hygiene she opened it with her bare hands mixed it to an apple sauce and gave it to R10. Prior to directly touching R10's medication, V5 was touching different objects and other surfaces. On December 30, 2025, at 2:57 PM, V12 (Nurse)…

    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 · D2025-12-31 · 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

    Based on observation, interview, and record review, the facility failed to apply a recommended device for contracture management to resident who has contractures. This applies to 2 of 3 residents (R3, R11) reviewed for contractures in the sample of 12. The findings include: 1. Face sheet shows R3 is 78 years-old who has multiple medical diagnoses including hemiplegia and hemiparesis affecting left non-dominant side. R3 is under hospice care. The therapy services/screening form dated September 16, 2025, shows R3 was provided a resting hand splint but it was missing, the facility notified hospice nurse. R3's care plan with a target date of January 1, 2026, shows, R3 has an ADL (Activities of Daily Living) self-care performance deficit related to hemiplegia, and left-hand contracture. This same care plan shows multiple interventions including application of left-hand splint, on for 12 hours and off for 12 hours. On December 28, 2025, at 10:48 AM, R3 was observed multiple times resting in bed, he was alert with periods of confusions. R3 displayed contracted to left arm and hand. R3's…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-31 · 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 follow physician order and manufacturer's recommendation for medication administration. There were 26 medication opportunities with 2 administration errors resulting to 7.69% medication error rate. This applies to 1 of 2 residents (R10) reviewed for medication administration in the sample of 12. The findings include:Face sheet shows that R10 is 92 years-old who has multiple medical diagnoses including dementia, dysphagia, hypertension, tachycardia, and hypothyroidism. On December 29, 2025, at 10:23 AM, V5 (Nurse) administered multiple medications to R10 including Levothyroxine and Aspirin chewable tablet. Both medications were crushed upon administration, which made the Aspirin medication an immediate release dose. V5 said that R10 already ate breakfast prior to administration of morning medications. On December 30, 2025, at 12:57 PM, V1 (Administrator) stated they expect the nurses to relay pharmacy recommendation to the physician and follow physician's instructions/orders. Synthroid is given early in 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 · Fcited before2025-01-30 · 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 clean and sanitize kitchen equipment, failed to label/date potentially hazadardous stored food, failed to store cooked meat to prevent cross contamination, and failed to perform hand hygiene per facility policy. This applies to all 22 residents residing in the facility. The findings include: Facility Long-Term Care Facility Application for Medicare and Medicaid, dated January 27, 2025, shows the facility census was 22 residents. On January 27, 2025, at 9:38 AM, during initial tour of the kitchen with V9 (Food Service Manager), the area behind/between large cooking equipment had a large amount of food splatters and food build up as well as dust with loose particles located behind and slightly above a pan of margarine melting on the flat top. The equipment hoses/cords and the back panels of equipment were covered in large amounts of dust and food splatter. On January 27, 2025, at 9:38 AM, during initial tour of the kitchen with V9, there was a package of four hot dogs (identified by V9) in the walk in cooler…

    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 · Fcited before2025-01-30 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their Water Management Plan for Legionella. The facility also failed to perform hand hygiene during provisions of care, failed to follow the EBP (Enhanced Barrier Precautions) policy, and clean medical equipment between resident use. This applies to all 22 residents residing in the facility. The findings include: 1. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated January 27, 2025, showed the facility census was 22 residents. The facility's Water Management Pan dated November 7, 2024, showed Purpose: The purpose of this Water Management Plan (WMP) is to establish the minimum legionellosis risk management requirements by illustrating the procedures for minimizing the risk of Legionnaires' disease within the building water systems of one facility . Control Measures: Cold Water Systems, Risk Factor: Eyewash Station, Control Measure: Plumbed units are to be activated weekly to flush the line and verify…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-30 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide the minimum required servings of fruits/vegetables and grains/breads on their planned menus as per facility policy. This applies to 15 of 15 residents (R1, R3, R7, R10, R11, R14, R15, R16, R18, R20, R127, R128, R129, R130, R176) reviewed for menu planning. The findings include: Facility Diet Type Report, dated January 29, 2025, shows R1, R3, R7, R10, R11, R14, R15, R16, R18, R20, R127, R128, R129, R130, R176 had physician orders for Regular and/or No Added Salt diets. Review of facility Regular/NAS (No Added Salt) menu, dated Week 3 Sunday through Week 3 Saturday, shows the facility failed to provide at least 5 fruits/vegetables planned on the daily menus 4 of 7 days (Sunday, Tuesday, Friday, and Saturday). The menu shows the facility failed to provide at least 6 servings of grains/breads on 2 of 7 days (Monday and Saturday). Review of facility Regular/NAS (No Added Salt) menu, dated Week 1 Sunday through Week 1 Saturday, shows the facility failed to provide at least 5 fruits/vegetables planned on the daily menus 4…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-30 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    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 give a resident a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF-ABN) at the end of a resident's Medicare Part A stay. This applies to 1 of 3 residents (R225) reviewed for beneficiary notices in the sample of 12. The findings include: The facility's SNF (Skilled Nursing Facility) Beneficiary Notification Review for R225 showed R225's Medicare Part A Skilled Services started on October 10, 2024 and last covered day of Part A services was November 14, 2024. The documentation continued to show R225 was not given a SNF ABN form. The EMR (Electronic Medical Record) showed R225 was admitted to the facility on [DATE], and was discharged from the facility on November 19, 2024, to the local hospital. On January 28, 2025, at 12:18 PM, V18 (Social Services) said R225 did not receive a SNF ABN form because V18 did not know R225 was going to remain in the facility after his last covered day of Medicare Part A. On January 28, 2025, at 1:02…

    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
Show the remaining 11 citations
  • Potential for harm · D2025-01-30 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    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 to the resident or resident's representative in writing the facility's bed hold policy when being transfer to the local hospital. This applies to 2 of 3 residents (R4 and R5) reviewed for hospitalizations in the sample of 12. The findings include: Facility provided their bed hold form titled, BEDHOLD AGREEMENT- TRANSFER NOTICE. The form showed the following information was required to be filled out: resident's name, date, the reason the resident being transferred to/for, why the transfer or discharge is necessary for the resident's welfare and the resident's needs, what was the bed hold decision, signature of facility representative, signature of resident/representative/responsible party who was given written notice of transfer, if needed phone confirmation, date, time, bed hold requested by, relationship to resident, confirmation received by facility representative signature. 1. R5's EMR (Electronic Medical Record) showed R5 was admitted 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-30 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident with significant weight loss was reviewed by a dietitian upon readmission to the facility from the hospital, failed to provide nutritional interventions to assist in preventing weight loss, and failed to obtain weekly weights as ordered by the physician. This applies to 1 of 1 residents (R3) in the sample of 12. The findings include: Face sheet, dated January 28, 2025, shows R3's diagnoses included pneumonitis due to inhalation of food and vomit, methicillin resistant staphylococcus aureus infection, osteomyelitis, severe protein-calorie malnutrition, acute respiratory failure with hypoxia, hemiplegia and hemiparesis following cerebral infarction, dysphagia, muscle wasting and atrophy, sepsis, iron deficiency anemia, vitamin D deficiency, major depression, epilepsy, chronic kidney disease, and hypoglycemia. Nutrition note, dated November 20, 2024, shows R3 had a history of significant weight loss and was receiving…

    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 · D2025-01-30 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    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 verify the placement and patency of a resident's gastrostomy tube (G-tube) before administering medication through it. This applies to 1 of 1 residents (R176) reviewed for gastrostomy tubes in the sample of 12. The Findings Include: R176' Resident Information sheet showed an [AGE] year old male admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, Dysphagia following Cerebral Infarction, Encounter for attention to Gastrostomy, and Type 2 Diabetes Mellitus. On January 28, 2025, at 8:36 AM, during medication administration observation, V6 (Nurse) entered R176 room with medications she had prepared outside of the room. V6 then removed the covers from over R176, lifted up his shirt. V6 picked up the end of R176's G-tube (where the catheter accesses were located), looked at it in her hand, and said, it look's okay. V6 then grabbed one 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-30 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 resident specific behaviors to monitor the effectiveness of psychotropic medications. This applies to 3 of 5 residents (R3, R5, and R75) reviewed for unnecessary psychotropic medications in the sample of 12. The findings include: Review of R3, R5, and R75's Documentation Survey Report, dated January 1, 2025 to January 29, 2025 showed all three residents were being monitored for the same behaviors. These included: 1. grabbing, 2. pinching, 3. scratching, 4. hitting/punching, 5. kicking, 6. pushing, 7. spitting, 8. biting, 9. sexually inappropriate, 10. verbal threatening, 11. screaming at others, 12. cursing at others, 13. hitting self, 14. scratching self, 15. pacing, 16. public sexual acts, 17. disrobing in public, 18. rummaging, 19. throwing/smearing food, 20. throwing/swearing bodily waste, 21, screaming/yelling out, 22. disruptive sounds, 23. attention seeking, 24. refusing care, 25. exit seeking, 26. wandering, 27. no behaviors observed.…

    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 before2025-01-16 · 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 follow their policy to answer call lights promptly and failed to provide timely incontinence care to a resident. This applies to 3 of 3 residents (R1, R3, R4) reviewed for call light response times in the sample of 4. The findings include: 1. The EMR (Electronic Medical Record) shows R3 was admitted to the facility on [DATE]. R3 has multiple diagnoses including, diabetes, atrial fibrillation, chronic kidney disease, heart disease, hypertension, difficulty walking, unsteadiness on the feet, morbid obesity, glaucoma, and dementia. R3's MDS dated [DATE] shows R3 is cognitively intact, requires setup with eating and oral hygiene, substantial/maximal assistance with bed mobility, and is dependent on facility staff for all other ADLs. R3 is always incontinent of bowel and bladder. R3's care plan entitled, At risk for alteration in skin integrity related to decreased mobility on a wheelchair, incontinent of bowel and bladder, and 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 before2024-04-19 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain the kitchen in a manner that prevents foodborne illness. This applies to all 26 residents that reside in the long-term care unit. Findings include: On 4/17/24 at 2:10 PM, V2 DON (Director of Nursing) stated the kitchen serves all 26 skilled residents. On 4/16/24 at 10:09 AM, the facility kitchen was toured with V9 (Cook / Kitchen Supervisor). V9 was observed with uncovered facial hair while working in the kitchen. The ice cream cooler had mint chocolate chip ice cream open and uncovered. On 4/16/24 at 10:12 AM, the dry storage area was toured. Blue bag filled identified by V9 as Raisins not labeled and without a date. Blue bag with identified by V9 as Craisins not labeled without a date. blue bag with identified by V9 as chocolate chips open to air. Bag identified by V9 as vermicelli not labeled or dated. Two 6lb cans of world horizon peaches dented in dry storage. V9 stated, the cans should not be in use as the dents cause the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-19 · 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 assist residents with their ADL (Activities of Daily Living) needs in a timely manner. This applies to 3 of 6 (R173, R18, R7) residents reviewed ADLs in a sample of 26. The findings include: 1. On 4/18/24 at 11:55 AM, R173 was observed sitting on the side of the bed in t shirt and disposable underpants. R173 stated it takes too long for staff to answer the call light and it makes her feel like they don't have enough help. R173 stated it took staff about 30mins to answer her call light, then she was left on the toilet waiting for staff to return to her. R173 stated she was not dressed because another staff member is supposed to assist her in getting dressed. R173 put her call light on while surveyor was in room. Surveyor went in hallway observed nursing staff at the nursing station and observed two nursing staff walk by R173 room without addressing call light. At 12:21 PM (26 minutes later), non-nursing staff noticed the Surveyor and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-19 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow Dietician recommendation to provide nutritional supplement to a resident with weight loss. This applies to 1 resident (R1) reviewed for weight loss in a sample of 12. The findings include: R1's Face sheet shows she is a [AGE] year old female with diagnoses of severe protein-calorie malnutrition, congestive heart failure, and need for assistance with personal care. R1's POS (Physician Order Sheet) shows R1 is a full code, and R1 is on a regular diet with level 5 minced and moist texture and thin liquids. The POS shows an order dated 3/28/24 stating her diet orders, including supplements, hydration program, and enteral nutrition may be delegated to Registered Certified Dietician. R1's Weights and Vitals Summary shows her weight on 3/6/24 was 110.8 lbs (pounds) and her weight on 4/6/24 was 95.4 lbs. In 1 month, R1 lost 15.4 lbs (13.9%). R1's Nutrition/Dietary note written on 4/9/24 at 10:07 AM by V11 (Dietician) states R1 has…

    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 before2024-04-19 · 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 disinfection protocol to prevent spread of infection. This applies to 2 residents (R14 and R175) reviewed for infection prevention and control in a sample of 12. The findings include: 1. R14's Face sheet shows the following diagnoses: congestive heart failure, severe protein calorie malnutrition, enterocolitis due to Clostridium Difficile (CDIFF), and need for assistance with personal care. R14's POS (Physician Order Sheet) shows order on 4/16/24 that states Strict Contact Isolation due to diarrhea, stool for CDIFF is ordered check that isolation set up and supplies are stocked by resident room. On 4/17/24 at 8:56 AM, V6 (RN/Registered Nurse) said she just collected stool to send and test for CDIFF because R14 has had frequent loose stools and a history of CDIFF. The sign on R14's door shows contact precautions, everyone who enters the room must wear gown and gloves. On 4/17/24 at 9:16 AM, V6 put on isolation gown and gloves and entered R14's room. While in R14's room, V6 placed pulse oximeter on his…

    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 · D2024-04-19 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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 offer and document the provision of the influenza and pneumococcal immunizations to residents admitted to the facility. This applies to 2 of 5 residents (R11, R124) reviewed for influenza and pneumococcal immunizations in a sample of 12. The findings include: On April 18, 2024, R11 and R124's electronic records were reviewed during the infection control task, and R11 and R124's vaccination records were not up to date. 1. R11's face sheet showed R11 was admitted to the facility on [DATE] with diagnoses including rhabdomyolysis, pleural effusion, congestive heart failure, chronic obstructive pulmonary disease, heart disease, and hypertension. R11's MDS (Minimum Data Set) dated March 20, 2024 showed R11 had mild cognitive impairment and required supervision for eating, oral hygiene, upper body dressing, and personal hygiene. R11 required substantial assistance from staff for toileting hygiene, shower/bathing, lower body dressing, and putting on/taking off…

    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 · D2024-04-19 · tag F0887 — isolated
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    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 offer, or document a history or refusal of, the COVID-19 immunizations to residents admitted to the facility. This applies to 2 of 5 residents (R124, R172) reviewed for COVID-19 immunization in a sample of 12. The findings include: On April 18, 2024, R124 and R172's electronic records were reviewed, and no documentation was found regarding administration or refusal of the COVID-19 immunization. 1. R124's face sheet showed R124 was admitted to the facility on [DATE] with diagnoses including trochanteric fracture of right femur, acute myocarditis, chronic obstructive pulmonary disease, congestive heart failure, hypertension, gastroesophageal reflux disease, and hyperlipidemia. R124's MDS (Minimum Data Set) was not due to be completed. R124's Immunization Report dated April 18, 2024 showed the COVID-19 vaccines were not addressed, including any historical administrations, and no consent or refusal for administration of the immunizations were documented…

    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

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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
BURR RIDGE SENIOR OPERATIONS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 03/01/2024
CHICAGOLAND SENIOR LIVING HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST100%since 03/01/2024
STESEL, MAXIMIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2024
WOODS, LYNNIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2024
HUSSAIN, JAWWADIndividualADP OF THE SNFsince 03/01/2024

CMS files one row per role, so the 9 rows in the source record cover these 5 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.

$8.9M
Net patient revenuemost recent cost report
-28.2%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 0%Medicare 10%Other / private 90%

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

$384per resident / day
operating cost
$11,683per month
≈ monthly operating cost
$300per 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

CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Illinois Medicaid page for homes that do.

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 146094. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-31, 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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