Aperion Care Chicago Heights
490 West 16th Place, Chicago Heights, IL 60411 · For profit - Corporation · 200 certified beds · (708) 481-4444 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- CMS has flagged it for abuse
- it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Mar 2026
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- about 24% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 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 2025-05 to 2026-06, this home’s CMS overall rating held steady at 2 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 0.7% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.1% | 6.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 97.9% | 54.2% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.5% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 1.1% | 14.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 9.1% | 18.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 96.6% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.6% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 3.9% | 20.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 94.3% | 21.7% | 17.1% | check this† — see note marked dagger below the table |
| Short-stay residents given the seasonal flu vaccine | 55.2% | 63.1% | 79.4% | worse |
† This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. 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.
Therapy staffing: this home’s payroll records show 0.07 therapist hours per resident per day in 2026Q1 — more than 4% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 35% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.2%CMS range 6.7–19.2 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.72 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 200 beds and averages 141.8 residents a day — about 71% occupied, or roughly 58 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 2.14 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.34 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.39 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 1.79 hrs/resident/day on weekends vs 2.29 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.38 to 0.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 53% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.
- Potential for harm · Dcited before2026-03-13 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident (R2) was free of physical abuse by another resident (R1) for two out of three residents reviewed for abuse in a total sample of nine. Findings Include: R1 is a [AGE] year old with the following diagnosis: schizophrenia and bipolar type schizoaffective disorder. R2 is a [AGE] year old with the following diagnosis: major depressive disorder, post-traumatic stress disorder and nonsuicidal self-harm. On 3/10/26 at 1:58PM, R2 was lying in bed and agreed to talk with the surveyor. R2 stated he got into a physical altercation with another resident (R1) about one to two weeks after R2 was admitted . R2 denied remembering the exact date of the altercation. R2 stated a heavy set black man hit R2 in the head and face more than once in the dining room. R2 denied remembering what led to the altercation but stated the other resident said words,' to R2 before hitting R2. R2 denied having any injuries. On 3/10/26 at 2:12PM, R1 was lying in bed 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.
- Potential for harm · Dcited before2026-03-13 · tag F0609 — failed to report abuse allegations — isolatedTimely 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of physical abuse to the state survey agency for one out of three residents reviewed for abuse reporting in a total sample of nine. Findings Include: R1 is a [AGE] year old with the following diagnosis: schizophrenia and bipolar type schizoaffective disorder. R2 is a [AGE] year old with the following diagnosis: major depressive disorder, post-traumatic stress disorder and nonsuicidal self-harm. On 3/10/26 at 1:58PM, R2 was lying in bed and agreed to talk with the surveyor. R2 stated he got into a physical altercation with another resident (R1) about one to two weeks after R2 was admitted . R2 denied remembering the exact date of the altercation. R2 stated a heavy set black man hit R2 in the head and face more than once in the dining room. R2 denied remembering what led to the altercation but stated the other resident said words,' to R2 before hitting R2. R2 denied having any injuries. On 3/10/26 at 2:12PM, R1 was lying in bed 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.
- Potential for harm · F2026-01-29 · tag F0805 — failed to prepare food in a form residents can eat — widespreadEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to follow policy by not matching residents' diet orders to food trays during meal service, and failed to have a system in place to ensure that the prescribed diet was served and ensured tray accuracy (that each resident receives food that is prepared in a form designed to avoid allergies and meet each individual's needs and preferences). These failures have the potential to result in residents receiving the wrong diet and can affect all 139 residents in the facility. Findings include: On 1/26/26 after the entrance conference, V1(Administrator) presented the facility census as 139. On 1/27/26 at 10:56am, V1 stated that all 139 residents receive oral foods from the kitchen.On 1/26/26 between 12:15pm and 12:45pm during lunch service, surveyors observed meal service to residents in the dining room. Dietary staff were observed dishing foods into each tray without tray cards and without any communication from the staff (V13/CNA/Certified Nurse Assistant) who was holding the Diet Order Report. Residents received 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.
- Potential for harm · F2026-01-29 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure that: food carts were free of dried food spills; the floor of the dry storage room was kept clean and free of visible dirt, and the wall air vent return was free of accumulated dust. These failures have the potential to affect all 139 residents that receive oral foods from the facility's kitchen. Findings include:On 1/26/26 after the entrance conference, V1(Administrator) presented the facility's census as 139. No residents have NPO status (receive nothing by mouth).On 1/12/26 between 9:35am and 10:00am during observation of the kitchen with V7(Dietary Manager), the floor of the Dry Storage Area of the kitchen was observed with visible accumulated dust, and visible dirt. V7 stated that the floor of the whole kitchen is supposed to be cleaned on supply days by the utility staff. Also, one kitchen cart was observed with dried food spills and visible dirt; V7 stated that the carts should be cleaned daily. In addition, the wall air return vent had a lot of accumulated dust. V7 stated that the vent would be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-01-29 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure that the outside dumpster garbage disposal was covered with the lids and failed to ensure that the floor around the dumpsters were free of bags of trash and spilled trash, thus creating an unsanitary environment. These failures have the potential to cause harboring of rodents which can affect all 139 residents in the facility.Findings include:On 1/26/26 after the entrance conference, V1(Administrator) presented the facility census as 139.On 1/26/26 at 9:52am, after kitchen observation with V7(Dietary Manager), the outside dumpster was observed to be open without lids, with bags of trash and spilled trash on the floor around the dumpster. V7 stated that the garbage truck should have come on Friday, and because of the weekend, the garbage was overflowing. Again on 1/26/26 at 11:20am, the surveyor observed the same dumpster still in the same condition without covers and with trash on the floor. On 1/27 26 at 10:20am, V7 stated that leaving dumpsters open could cause rodents to come around the building, 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.
- Potential for harm · F2026-01-29 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 that staff sanitize the tables in the dining area in between residents and failed to ensure that residents were assisted with hand hygiene before eating. This failure has the potential to affect all 139 residents currently residing at the facility. Findings include:Resident census provided by V1 (Administrator) upon entrance- 139.On 1/26/2026 at 12:18PM during lunch observation, surveyor observed that the facility is using one dining room for all the residents. Some residents were already eating, while others were observed lined up in the hallway, waiting to be called. The residents who finished their food were noted leaving the dining area with their tray, while other residents will come in and sit on the same spot just vacated by another resident. Some of the tables were noted with food crumbs and garbage left by residents who have finished eating and the one coming in will just sit and eat on the dirty table. There is no organization as to who sits where, or the number of residents eating at 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.
- Potential for harm · Fcited before2026-01-29 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to follow policy and procedure and failed to clean the lint screen thoroughly to provide a safe environment for the residents. This failure has the potential to affect all 139 residents at the facility.Findings include:Facility census dated 1/26/26, documents 139 residents residing in the facility.On 1/27/26 at 11:36am, accompanied by V10 (EVS/Environmental Services Supervisor), a tour of the facility's laundry room was conducted. V10 opened the lint compartment for dryer #3 and the lint compartment floor had loose lint on the floor and the lint screen was fully covered with lint. V10 said, Uh oh. Looks like they (laundry staff) didn't clean the lint out today. V10 removed the lint from the lint screen and the bottom of the compartment floor and disposed of the lint in the trash. V10 stated, We (laundry staff) clean the lint compartments out every Monday, Wednesday, and Friday because we (facility) launder out most of the laundry. The facility dryers are used for rags and maybe a few other things. The lint is…
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.
- Potential for harm · F2026-01-29 · tag F0924 — widespreadPut firmly secured handrails on each side of hallways.
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 secure handrails to the corridor walls. This failure has the potential to affect all 139 residents that reside within the facility.Findings include:Facility census (1/26/2026) documents in part that 139 residents reside within the facility.On 1/26/2026 at 10:25 AM, observed the handrail next to room [ROOM NUMBER] loose and able to be displaced 4-5 inches on the wall and unsecured to the wall. V1 (Administrator) observed the handrail and confirmed the findings. V1 stated the purpose of handrails is for safety and to prevent falls.On 1/26/2026 at 10:28, observed V1 testing other handrails down the corridor to check if they were firmly secured and observed walking with a cane down the hallway with an abnormal gait. V1 grabbed the handrail outside of the master shower room, near 143 and the rail fully detached from the wall and hit the floor. R19 was visibly startled and told V1, Wow that really could have hurt me.R19's care plan documents R19…
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.
- Potential for harm · Ecited before2026-01-29 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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 ensure that five residents (R52, R64, R93, R119 and R136) had a clean and sanitary bathroom. This failure affected a total of five residents reviewed for resident's rights to enjoy a clean, homelike environment, in a total sample of 54 residents.Findings include: On 1/26/26 at 10:29am, upon entering R52's and R64's room, a strong, pervasive odor of urine was detected. Upon entering R52's and R64's, which is also shared with R93, R119 and R136, a large puddle of urine which spread out from the area around the toilet was observed. On 1/26/26 at 10:30am, R52 said, I don't know who pissed on the floor. It (R52's and R64's) always smells like piss in here. R52's face sheet documents diagnoses that include but are not limited to psychosis, schizophrenia, hallucinations, and violent behavior. R52's BIMS (brief interview for mental status) score, dated 1/14/2026, is 12 which indicates R52's cognition is moderately impaired. On 1/26/26 at 10:33am, R64 said, There's been pee on our bathroom floor before. Sometimes, 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.
- Potential for harm · D2026-01-29 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their comprehensive care plan policy by failing to develop a person centered care plan for a resident to include measurable objectives and timeframes to meet the resident's medical and nursing needs that were identified in the comprehensive assessment for Anemia, Type 2 Diabetes Mellitus, Hypertension, and Hyperlipidemia for one (R20) resident of 54 residents reviewed for care plans.Findings include:R20 is [AGE] years of age. Current diagnoses include but are not limited to Type 2 Diabetes Mellitus, Hypertension, Hyperlipidemia, Anemia, Pyothorax without Fistula, Emphysema, Paranoid Personality Disorder, Pneumonia, and Paranoid Schizophrenia.R20's comprehensive assessment section C Cognitive Patterns dated 01/14/2025 documents a brief interview for mental status score of 15 which indicates R1 is cognitively intact.On 01/27/2026 at 2:25 PM, V21 MDS (Minimum Data Set) Coordinator was inquired of R20 not having a care plan for his medical…
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.
Show the remaining 18 citations
- Potential for harm · Dcited before2026-01-29 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 staff carry out physician orders and failed to ensure that resident received ordered medications for his skin condition. This failure affected one (R2) of one resident reviewed for skin condition in a total sample of 54.Findings include:R2 is [AGE] years old and have resided at the facility since 2024, face sheet lists the following medical history: major depressive disorder, bipolar disorder, cellulitis lower limb, type 2 diabetes, essential primary hypertension, hypothyroidism, etc.On 01/26/2026 at 10:10AM, R2 was noted with very dry scaly skin on both hands and legs, he stated that he can take his own shower, the dry skin is from eczema, he is supposed to get a cream three times a day, but the nurses do not give it to him, they tell him that he was supposed to remind them. On 01/27/2026 at 9:50 AM, R2 was observed again still with dry scaly skin on both hands and legs, stated that he did not get any cream yet.Per record…
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.
- Potential for harm · D2025-12-24 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide care in accordance with professional standards for medication administration during an emergency crisis when one resident (R1) was found unresponsive and administered insulin. This failure affected one (R1) of four residents reviewed for medication administration and has the potential to affect 43 residents identified as having diagnosis of Diabetes Mellitus in the facility.Findings include:R1 's medical record showed that R1 was admitted to the facility on [DATE] with diagnosis list that includes but not limited to Type 2 diabetes Mellitus without complications, epilepsy unspecified not intractable with status epilepticus, other seizures, unsteadiness on feet and schizoaffective disorder, depressive type. R1 expired on [DATE] at the hospital.R1's medical record showed that R1 was found unresponsive on [DATE] at 5:30am with blood sugar 290(MG/DL).R1's Medication Administration Record dated [DATE] at 6:00am documents V11, Registered 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.
- Potential for harm · Dcited before2025-07-22 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 for abuse by failing to protect residents from physical abuse. This failure applies to two of three residents (R1 and R2) reviewed for abuse.Findings include: 1. R1 is a [AGE] year-old male with a diagnoses history of Paranoid Schizophrenia, Generalized Anxiety Disorder, Secondary Parkinsonism, and Dystonia (Involuntary Muscle Contractions) who was admitted to the facility 11/23/2022. On 07/21/2025 at 1:27 PM When asked by surveyor if he had an incident with R2 a week ago on 07/15/2025 R1 stated he ran over R2's foot and didn't know it, R2 hit him and he hit R2 back, then he pushed R2 down on the floor, a female staff broke it up, his head was hurt and he has a bump on his head, R1 stated he didn't want to fight, then showed the surveyor a small bump on the left side of his forehead and stated that's where R2 hit him on his head. R1's Annual Minimum Data Set documents his BIMS (Basic Interview for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-22 · tag F0609 — failed to report abuse allegations — isolatedTimely 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
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 for abuse by not reporting an allegation of physical abuse to the state agency. This failure applies to two of three residents (R1 and R2) reviewed for abuse.Findings include: The facility did not provide any abuse investigation reports or documentation of any abuse investigation reports being submitted to the state agency for July 2025 in response to the surveyor's request upon survey entrance for any reportable investigations including interviews and witness statements. On 07/21/2025 at 10:55 AM V1 (Administrator) stated there had not been any reportable events in the facility in July 2025. 1. R1 is a [AGE] year-old male with a diagnoses history of Paranoid Schizophrenia, Generalized Anxiety Disorder, Secondary Parkinsonism, and Dystonia (Involuntary Muscle Contractions) who was admitted to the facility 11/23/2022. On 07/21/2025 at 1:27 PM When asked by surveyor if he had an incident with R2 a week…
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.
- Potential for harm · D2025-07-22 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 for abuse by not investigating an allegation of physical abuse. This failure applies to two of three residents (R1 and R2) reviewed for abuse.Findings include: 1. R1 is a [AGE] year-old male with a diagnoses history of Paranoid Schizophrenia, Generalized Anxiety Disorder, Secondary Parkinsonism, and Dystonia (Involuntary Muscle Contractions) who was admitted to the facility 11/23/2022. On 07/21/2025 at 1:27 PM When asked by surveyor if he had an incident with R2 a week ago on 07/15/2025 R1 stated he ran over R2's foot and didn't know it, R2 hit him and he hit R2 back, then he pushed R2 down on the floor, a female staff broke it up, his head was hurt and he has a bump on his head, R1 stated he didn't want to fight, then showed the surveyor a small bump on the left side of his forehead and stated that's where R2 hit him on his head. R1's Annual Minimum Data Set documents his BIMS (Basic Interview for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-05 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to follow their Physician's Order Policy by failing to discontinue medication as ordered by the physician. This deficient practice affects one resident of three residents reviewed for medication administration. This failure resulted in R3 receiving extra dosages of antiepileptic medication. Findings Include: R3 admitted in the facility on 2/28/25. R3 has a diagnosis of Symptomatic Epilepsy and Epileptic Syndromes with Complex Partial Seizure. R3 admitted in the facility with medications such as, but not limited to: Brivaracetam 100mg (milligrams) two times daily for seizure, Clobazam 10mg at bedtime for seizure, Divalproex Sodium 500mg two times daily for seizure, and Levetiracetam (Keppra) 750mg two times daily for seizure with order date of 2/28/25. R3's Neurology note dated 5/6/25, reads in part: R3 should NOT be prescribed Levetiracetam (Keppra) at the same time she is taking Briviact (Brivaracetam). Please discontinue Keppra. This was communicated to the ADON in the facility by phone on 4/23/25. After Visit Neurology…
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.
- Potential for harm · Dcited before2025-05-11 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and records review, the facility failed to administer medications to one (R1) of three residents reviewed for medication administration in a total sample of six. Findings include: Medical diagnosis in R1's current face sheet includes but not limited to: bipolar disorder, unspecified, schizophrenia, unspecified, hemiplegia, unspecified affecting right dominant side, personal history of traumatic brain injury. On 05/10/2025, at 9:30 AM, R1 was observed laying in bed talking to his roommate R4. R1 stated on 4/26/2025 going into 4/27/2025, he did not receive his pain medication during the night and he was in a lot of pain. R1 stated he asked V10 (Registered Nurse-Agency) for his medication but V10 told R1 that his medication was not available. R1 stated he asked for his medication the whole night but V10 kept saying medication was not available and there was nothing V10 could do about it. R1 stated he had to try and sleep with his pain until the following morning when the morning nurse gave him his pain medication. On 05/10/2025, at 4:00 PM, V1 (Administrator) stated…
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.
- Potential for harm · D2025-02-23 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to follow the discharge policy and give a copy of notice to discharge to the resident representative for one of three residents (R1) reviewed for discharge notice. Findings include: R1 face sheet shows diagnosis of schizophrenia, anxiety disorder, schizoaffective disorder, non-compliance with medication regimen for other reasons. R1 MDS dated 10/2024 section Q denotes yes, that R1 plan to return to the community, section C for cognition, R1 BIMS score is 15 (cognitively intact), section GG for functional abilities shows R1 helper provides verbal cues for activities of daily living. On 2/22/25 at 10:18am V2 said R1 was involuntary discharged because R1 physically assaulted the staff, the safety of individuals in the facility is endangered due to R1 behavior/physical assault. V2 said R1 guardian received verbal notice of the transfer and discharge however she did not give R1's guardian a copy of the notice of involuntary transfer or discharge and opportunity for hearing for nursing home residents. Review of the notice with V2,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-09 · tag F0609 — failed to report abuse allegations — isolatedTimely 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, the facility failed to report an allegation of resident to resident abuse to the State Survey Agency for two of two residents (R292 & R105) reviewed for abuse in the sample of 39 residents. Findings including: On 1/6/25 at 10:30 AM, survey team requested V1 (administrator and abuse prohibition coordinator) all reportable incidents within the last 90 days. V1 presented the survey team with 3 incidents reported to public health regional office (RO) however did not have the incident of 12/18/24 involving R292 and R105. On 1/7/25 at 11:15 AM, V1 (administrator) stated to survey team that the incident on 12/18/24 involving R292 did not warrant reporting as it did not involve another peer (resident).Surveyors asked who was involved in the incident altercation, V1 indicated that R292 struck the CNA V19. Surveyors clarified if R292 had any physical or verbal altercation with any resident during this incident, V1 stated, No, only with staff members. On 12/18/2024 at 19:20 PM, V8 (Social Services) wrote, Note Text: It was reported that this resident…
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.
- Potential for harm · D2024-11-22 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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
Based on interview and record, the facility failed to follow their policy by failing to notify the responsible party for a resident when the resident was discharge to the hospital. This failure affected one of three (R1) residents reviewed for notification on the sample list of six. Findings Include: On 11/21/24 at 1:50pm, V10 (R1's guardian) said, she was not notified when R1 was discharged to the hospital. On 11/22/24 at 10:17am, V29 (nurse) said, all of R1's paperwork and notifications were done prior to her shift. V29 said, her duty was to wait to the hospital to call to accept R1, call the ambulance to pick up and send R1 to the hospital. V29 said, she would call the family after the resident has been admitted to the hospital. V29 said, R1 was not admitted to the hospital prior to the end of her shift. R1 was under observation. V29 said, she did not do any notify R1's guardian because R1 was not admitted . On 11/22/24 at 2:04pm, V1 (administrator/nurse) said, R1 does not have any notification in her electronic record to R1's guardians prior to R1 being sent to the hospital.…
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.
- Potential for harm · D2024-08-23 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure a resident was free from misappropriation of his property. This applies to 1 of 3 residents (R1) reviewed for abuse/misappropriation in the sample of 6. The findings include: The facility reported incident dated 7/11/24 states, (R1) stated that he asked a staff member, (V6) to take his link card to purchase him some beverages at the store. (R1) stated that the staff member never returned his card. (V6) is no longer an employee of the facility. (R1) canceled his Link card and the money will be transferred to his new card. No observations of emotional nor mental distress noted. On 8/23/24 at 10:45 AM, R1 was ambulating in the hall towards his room. R1 agreed to speak with Surveyor in his room. R1 stated, Someone took my (Link) card- I thought I gave it to someone I could trust to get me some snacks and they never brought it back. I have a card now (Resident removed card from his pocket and showed it to Surveyor) but there is no money on it. I know the police were here and that scared me because I didn't do…
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.
- Potential for harm · E2024-07-19 · tag F0607 — failed to have anti-abuse policies — patternDevelop 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 written policies and procedures that prohibit and prevent abuse. This deficiency affects all four (R29, R81, R103 and R192) residents in the sample of 27 reviewed for Abuse prevention Program. Findings include: R192 is admitted on [DATE] with admitting diagnosis listed in part but not limited to Schizophrenia, Psychosis, Bipolar disorder, and anxiety disorder. No abuse/neglect screening assessment done upon admission and after incident of resident-to-resident alteration on 6/27/24. Care plan indicates: He is sexually active or has been sexually active during my tenure in this facility. He has history of criminal behavior related to battery. He has been deemed a moderate risk. He displays manipulative behavior by creating fabricating conversation. He uses psychotropic medications related to behavior management of Schizophrenia, bipolar and anxiety. No care plan formulated for abuse prevention. Care plan was not updated after…
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.
- Potential for harm · Dcited before2024-07-19 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to administer medications as ordered for 1 of 3 residents (R135) reviewed for medication administration in a sample of 27. Findings include: On 7/17/2024 at 11:00am V13 (Licensed Practical Nurse-LPN) was asked did R135 have an appetite stimulant available. V13 said yes, I administered it to R135 this morning and threw away the bottle R135 does not receive another dosage until tomorrow in the am, here's R135 two bottles of appetite stimulant, observed un-opened seals unbroken. On 7/17/2024 at 12:00 noon R135 was observed in the dining area completing his lunch, R135 was asked did the nurse administer any medication before eating lunch? R135 said no I didn't have any medication I never do; I did not refuse it. On 7/17/2024 at 12:05pm surveyor asked V13 to observe the two bottles of appetite stimulant, both bottles were un-opened seals not broken. V13 and the surveyor read the order for the appetite stimulant. Which said megestrol acetate oral suspension give 5ml by mouth before each meal for appetite stimulant…
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.
- Potential for harm · Dcited before2024-06-14 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure 1 of 3 residents (R4) reviewed for abuse in the sample of 11 was free of resident to resident physical abuse. The findings include: On 6/14/24 at 11:25 AM, R4 said R3 hit her eye about a month or two ago. R4 said she was just sitting and eating a candy bar and R3 just came up and hit her in the eye. R4 said she does not know if anyone saw it happen, but she called for a nurse to help her. R4 said she did not go to the hospital and her right eye was red at first, but everything ended up being OK. On 6/14/24 at 10:03 AM, R3 said she muffed R4, but now they get along. When asked what muffed means, R3 demonstrated pushing her fingers into the middle of her forehead and causing her head to go back. On 6/14/24 at 12:12 PM, V16, Registered Nurse (RN), said a staff member (cannot recall who), came and reported that R3 and R4 were arguing and by the time she got to R4's room, R3 was not there and R4 had a red eye. R4 told V16 that R3 asked R4 for something and R4 said no and an altercation started and R3 hit R4 in the eye.…
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.
- Potential for harm · Ecited before2024-03-02 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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 observations, interviews, and record reviews the facility failed to follow their policy for facility maintenance by not ensuring handrails were installed in a manner that was nonhazardous to residents. This failure affects four of four residents (R1, R2, R3 and R4) reviewed for environment on the sample list of five. Findings include: R1 is a [AGE] year-old female with a diagnoses history of Schizoaffective Disorder Bipolar Type, Schizophrenia, and Thyroid Disorder who was admitted to the facility 09/09/2021. On 03/01/2024 from 2:07 PM - 3:05 PM R1 stated the handrails throughout the hallway have nails sticking out of them and if someone places their hand around the rail they could get hurt. Observed multiple railings throughout the hallways of the facility with large, exposed nails on the sides between the rail and the wall. Observed end cap missing from a handrail with exposed nails. On 03/01/2024 at 3:12 PM V1 (Administrator) stated the handrails at the facility had been repaired including the end…
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.
- Potential for harm · Dcited before2024-03-02 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to follow their policy and procedures for administering medications by not ensuring a resident's medication was available for administration, not ensuring the resident received their own personally prescribed medication, not documenting the administration of the resident's medication in their medical records. This failure applied to one of four residents (R1) reviewed for medication administration on the sample of five. Findings include: R1 is a [AGE] year-old female with a diagnoses history of Schizoaffective Disorder Bipolar Type, Schizophrenia, and Thyroid Disorder who was admitted to the facility 09/09/2021. On 03/01/2024 from 2:07 PM - 3:05 PM R1 stated R1 stated the wrong medication was given to her by V4 (Licensed Practical Nurse) and V3 (Assistant Director of Nursing). R1 stated she became sick for weeks after this and they were laughing at her. R1 stated she had a dry mouth and headache after receiving the wrong medication. R1 stated V1 is…
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.
- Potential for harm · Fcited before2023-11-16 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide to the residents a safe and comfortable home-like environment that supported and enhanced each resident's overall quality of life by not maintaining an effective housekeeping and preventative maintenance plan due to the overall visibly uncleaned and unkept appearance the resident living areas, missing and/or visibly damaged railings and baseboards, walls and floors visibly stained with brown to black colored stains throughout resident common areas, resident rooms, dining room, bathrooms and hallways throughout unit one, and the presence of black flying insects within the hallway and main kitchen area. This failure directly affected three residents (R1, R2, R3) and cumulatively affects all 123 residents who currently reside at the facility. Findings include: On 11/13/2023 at 09:50 AM, V2 (Assistant Administrator) said the current resident census is 123 in-house. On 11/13/2023, reviewed pest inspection report summaries from…
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.
- No harm found · Ccited before2024-07-19 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to provide a functional Eyewash Station where hazardous chemicals are used. This deficiency affects all units, reviewed for environmental safety. Findings include: On 7/17/24 at 2:02PM, V11(Maintenance Director) said that the eyewash station has not been logged since February 2024 because in January 2024 the caps for eyewash station were broken. V11 said that an order for replacing the eyewash caps was done in January 2024, however, V11 did not present an invoice for order dated January 2024. V11 said no further logs available because they were not done. On 7/17/24 at 2:30PM, V11 provided an invoice dated 7/17/2024 for order of eyewash float-off dust covers. On 7/18/24 at 10:48AM, V3 (Infection Preventionist) said the eyewash station is used in case of emergency where hazardous chemicals are used, and it should be always functional. V3 said she was unaware eyewash station was not functional. On 7/18/24 at 1:22PM, V1 (Administrator) said eyewash station should be functioning at all times. V1 said she was unaware…
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.
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to APERION CARE — 33 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 1.9 | +0.1 vs chain |
| Health inspection | 2 of 5 | 2.0 | ≈ chain avg |
| Staffing | 1 of 5 | 1.6 | -0.6 vs chain |
| Quality measures | 5 of 5 | 3.3 | +1.7 vs chain |
The other 32 homes this chain runs (chain average 1.9★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| 417A LIMITED PARTNERSHIP | Organization | DIRECT OWNERSHIP INTEREST | since 05/01/2008 |
| BIDER FAMILY TRUST | Organization | DIRECT OWNERSHIP INTEREST | since 05/01/2008 |
| DENNIS RIBEN TRUST DTD 12/7/87 | Organization | DIRECT OWNERSHIP INTEREST | since 05/01/2008 |
| ISADORE MEYSTEL REVOCABLE TRUST | Organization | DIRECT OWNERSHIP INTEREST | since 05/01/2008 |
| JAY MEYSTEL TRUST | Organization | DIRECT OWNERSHIP INTEREST | since 05/01/2008 |
| JOYCE L. RUBEN TRUST DTD 11/16/94 | Organization | DIRECT OWNERSHIP INTEREST | since 05/01/2008 |
| CHAVIN, RACHEL | Individual | DIRECT OWNERSHIP INTEREST | since 05/01/2008 |
| INOFRE, CHRISTINA | Individual | DIRECT OWNERSHIP INTEREST | since 05/01/2008 |
| LAFER, REBECCA | Individual | DIRECT OWNERSHIP INTEREST | since 05/01/2008 |
| STEIN, ZALMEN | Individual | DIRECT OWNERSHIP INTEREST | since 05/01/2008 |
| WEINSTOCK, DAVID | Individual | DIRECT OWNERSHIP INTEREST | since 03/23/2026 |
| WROTSLOVSKTY, SHELDON | Individual | DIRECT OWNERSHIP INTEREST | since 05/01/2008 |
| CRISLER, CRISTINA | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2008 |
| JUDE, JODIE | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 05/01/2008 |
| SPECTOR, JENNIFER | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 05/01/2008 |
| APERION CARE INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/18/2025 |
| BARNABAS, SATISH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2008 |
| TAYLOR, KATHLEEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2008 |
| ULBERT, LISA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 05/01/2008 |
| WILHELM, NAFTALI | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 05/01/2008 |
| BERKOWITZ, DAVID | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 06/25/2025 |
| MEYSTEL, YOSEF | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 06/25/2025 |
| 1219 LIMTED PARTNERSHIP | Organization | ADP OF THE SNF | since 01/30/2008 |
| 257 LIMTED PARTNERSHIP | Organization | ADP OF THE SNF | since 01/01/2010 |
| 42170 LIMTED PARTNERSHIP | Organization | ADP OF THE SNF | since 01/30/2008 |
| APERION CONSULTING, LLC | Organization | ADP OF THE SNF | since 05/01/2008 |
| CURIS SERVICES LLC | Organization | ADP OF THE SNF | since 05/01/2008 |
| DAVID A BERKOWITZ REVOC TR DAVID BERKOWITZ TTEE | Organization | ADP OF THE SNF | since 05/01/2008 |
| DECLARATION OF TRUST OF YOSEF MEYSTEL | Organization | ADP OF THE SNF | since 10/01/2012 |
| RIVIERA REALTY, LLC | Organization | ADP OF THE SNF | since 03/18/2025 |
| TUROFSKY, STEVEN | Individual | ADP OF THE SNF | since 05/01/2008 |
CMS files one row per role, so the 38 rows in the source record cover these 31 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
15 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.
This home reported $3.1M paid to related parties — landlords or management companies under common ownership — equal to about 24% 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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
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 145180. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-29, 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.