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Admiral At The Lake, The

933 West Foster Avenue, Chicago, IL 60640 · Non profit - Corporation · 36 certified beds · (773) 654-5121 Medicare only — no Medicaid

Call the home — (773) 654-5121 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation
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)
  • lower-than-typical staff turnover (15% vs 45% nationally) — better care continuity
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1039 W Winona St · (708) 635-9955 · Call to confirm hours
Pharmacy
Mariano's<0.1 mi
5201 N Sheridan Rd · (773) 506-0910 · Call to confirm hours
Grocery
5343 N Sheridan Rd · (773) 989-1930 · Call to confirm hours
Park
Lake Front Path · 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 3 of 5
Short-stay residentsrehab / post-hospital 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 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased7.1%13.4%15.4%better
Long-stay residents who lose too much weight10.1%6.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.7%0.9%0.9%better
Long-stay residents with a urinary tract infection0.0%1.5%2.0%better
Long-stay residents with depressive symptoms0.0%54.2%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury8.2%3.1%3.3%worse
Long-stay residents on antianxiety or hypnotic medication5.5%18.3%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%91.8%95.3%typical
Long-stay residents with pressure ulcers15.5%4.8%4.7%worse
Long-stay residents with worsening bladder/bowel control4.2%20.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table19.4%21.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.6%2.2%1.4%worse
Short-stay residents given the seasonal flu vaccine90.3%63.1%79.4%better
Short-stay residents rehospitalized after admission30.9%26.1%22.6%worse
Short-stay residents with an outpatient ER visit6.0%13.9%12.0%better
Long-stay hospitalizations per 1,000 resident days3.832.021.67worse
Long-stay outpatient ER visits per 1,000 resident days0.882.221.80better

* 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.

§ 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.

65.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 77 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

65.2%U.S. median 51.5%
Got home and stayed home
9.2%U.S. median 10.7%
Went back to hospital
60.4%U.S. median 56.6%
Met the expected recovery
0.38U.S. median 0.31
Therapy hours / resident / day
0.22hours / resident / day
Physical therapy
0.16hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 60.4% 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 53 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.38 therapist hours per resident per day in 2026Q1 — more than 65% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF65.2%CMS range 54.8–73.251.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.2%CMS range 6.4–13.010.7%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 discharge60.4%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 discharge60.4%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 discharge67.9%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 identified97.7%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 setting93.9%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 discharge100.0%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 stay2.4%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 hospitalization6.3%CMS range 3.6–12.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.031.02Oct 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

1.04
RN hours/ resident / day
0.70
LPN hours/ resident / day
2.71
Aide hours/ resident / day
4.45
Total nurse hours/ resident / day
0.69
RN hoursweekends
15.2%
Total nursing turnover
42.9%
RN turnover

How full it usually is: this home is certified for 36 beds and averages 28.4 residents a day — about 79% 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 4.45 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.04 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.71 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 3.98 hrs/resident/day on weekends vs 4.64 on weekdays — 14% thinner on weekends. RN hours go from 1.18 to 0.69 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 15% is below the national median of 45%.

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

Inspection trend

6
deficiencies at the latest standard inspection (2026-03-05)
7
at the previous standard inspection (2025-01-24)

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.

25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.

  • Actual harm · Gcited before2025-06-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review facility failed to perform accurate fall risk assessment for a resident with a known fall history, develop and implement post fall interventions to prevent future falls and failed to monitor, document, and send resident to hospital in a timely manner post fall incident for one resident (R2) out of four residents reviewed for accident and supervision. This failure led to R2 falling in the facility sustaining multiple acute fractures. Findings Include: R2's Minimum Data Set (MDS) dated [DATE] shows he is cognitively impaired. R2's electronic medical record (EMR) revealed R2 was initially admitted to the facility on [DATE] and was [AGE] years old with diagnoses of, but not limited to unspecified fall, subsequent encounter, malignant neoplasm of bladder, heart failure, unspecified atrial fibrillation, hypertension, unsteadiness on feet, muscle weakness generalized, chronic kidney disease, diverticulitis of intestine with perforation and abscess with bleeding. On 6/3/25 at 1:53…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2026-03-05 · 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 label and date opened food stored in the refrigerator and freezer, failed to discard expired food, failed to use hair nets while working in the kitchen. Failed to store food off the floor. This failure has the potential to affect all residents that receive oral diets.Findings include:On 03/02/26 at 9:28am observed facility's walk-in refrigerator with open containers of mixed fruit, muffin mix, hamburger patties, [NAME] slaw, hot dogs, sliced American cheese, egg mix all with no open or discard date. Observed plastic wrapped containers with tomatoes, carrots, lettuce, cucumber and watermelon with a use by date of 03/01/26.On 03/02/26 at 9:28am V19 (Sous Chef) stated that it is important to date the food so that the staff know when it expires. V19 stated that the food that is expired is garbage.On 03/02/26 at 9:42am observed facility's walk-in freezer with 6 buckets of ice-cream, a tray of veggie burgers and a tray of chicken patties with no…

    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 before2026-03-05 · 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 perform hand hygiene between passing dining trays, failed to clean multi use equipment after use for two residents (R2 and R11), failed to perform hand hygiene after caring for one resident (R6), failed to wear PPE (Personal Protective Equipment) while caring for one resident (R17) on EBP (Enhanced Barrier Precautions), failed to perform hand hygiene during resident ADL (activities of daily living) care for one resident (R20), failed to store clean and soiled linen in a way to prevent the spread of infection. This failure affected five residents (R2, R6, R11, R17, R20) and has the potential to affect all residents that reside in the facility. Findings include: R17's medical diagnoses include but are not limited to major depressive disorder, paraplegia, neuromuscular dysfunction, type 2 diabetes. R17's care plan revised 01/13/26 documents in part, R17 is placed on EBP per facility's protocol d/t (due to) indwelling urinary device. R17 will…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-03-05 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, facility failed to follow their policy and failed to properly label and marked open medications with opened date and failed to remove expired insulin from the medication cart. These failures affected five residents (R2, R9, R19, R28 and R30) residing on the 8th floor of the facility and have the potential to affect all 14 residents residing on the 8th floor unit of the facility.Findings include:On [DATE] at 9:31 AM, facility presented a census of 30 residents living at the 8th and the 9th floor units. Census showed 14 residents residing on the 8th floor unit.On [DATE] at 11:58 AM, observed 8th floor unit's medication room with V4 (Licensed Practical Nurse/LPN). Found the following in the 8th floor unit medication room refrigerator:R9's Lorazepam oral concentrate solution, 30ml bottle 2mg/ml, opened with no open date marked. R19's Lorazepam oral concentrate solution, 30ml bottle 2mg/ml, opened with no open date marked.On [DATE] at 12:59 PM, observed 8th floor…

    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 · D2026-03-05 · 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 identify, document, and report a new skin alteration (bruise) which affected one resident (R20) reviewed for skin conditions in the total sample of 30 residents. Findings include:On 3/2/2026 at 11:29 AM, V6 (Care Partner, Certified Nursing Assistant, CNA) observed in R20's room and assisting R20 (one person assist) from the bed to the wheelchair. V6 wheeled R20 into the bathroom, and R20 stood using the grab bars for assist and pulled down R20's pants and brief with V6 standing next to R20. This surveyor visibly observed a bruise on R20's left lateral thigh, purple in color, and approximately 3 inches by 2 inches in size. On 3/3/2026 at 10:55 AM, R20 stated that R20 doesn't know about the bruise on R20's left lateral thigh and said, I (R20) always bump into things. R20 gave permission for this surveyor to view R20's skin assessment from the nurse, and R20 pressed R20's call light.On 3/3/2026 at 10:58 AM, V4 (Licensed Practical Nurse, LPN)…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, facility failed to implement their policy and failed to ensure that oxygen equipment was properly contained when not in use for two residents (R8 and R24); Failed to properly label and date one resident's (R13) oxygen equipment and failed to discard/replace unused expired oxygen tubing for one resident (R8). These failures affected three residents reviewed for respiratory care in the final sample of 30 residents.Findings include: On [DATE] at 9:31 AM, facility presented a census of 30 residents living at the 8th and the 9th floor units. On [DATE] at 10:45 AM, observed in R8's room unused oxygen machine positioned next to R8's bed. Observed next to oxygen machine an oxygen tubing stuck in R8's dresser drawer sticking out and hanging down, all the way to the floor. The connecting end portion of the tubing was coiled on the floor, completely resting on the floor with labeled date on the tubing of [DATE]. R8 stated that R8 used oxygen in the past, but currently…

    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 · D2025-06-06 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews, the facility failed to review and revise the comprehensive resident-centered care plan for one resident (R2) out of four residents reviewed for care plan revision. Findings Include: R2's Minimum Data Set (MDS) dated [DATE] shows he is cognitively impaired. R2's electronic medical record (EMR) revealed R2 was initially admitted to the facility on [DATE] and was [AGE] years old with diagnoses of, but not limited to unspecified fall, subsequent encounter, malignant neoplasm of bladder, heart failure, unspecified atrial fibrillation, hypertension, unsteadiness on feet, muscle weakness generalized, chronic kidney disease, diverticulitis of intestine with perforation and abscess with bleeding. On 6/3/25 at 3:30 PM, V2 (Director of Nursing/Fall Coordinator) stated she has been in the facility since August 2024, she collaborates with the care plan coordinator to update the care plan with new interventions to prevent further falls. On 6/4/25 at 2:44 PM, V2 state if a 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-01-24 · tag F0804 — failed to serve food at safe, palatable temperature — widespread
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to follow their policies and implement safe food preparation and services to ensure the food conserves a safe temperature. This failure has the potential to affect all residents that receive nutrition from the kitchen. Findings include: On 1/21/2025 at 9:38 AM, this surveyor reviewed facility dated 1/21/2025 titled Hot holding (main kitchen) temperature log does not document a temperature was taken for the breakfast food (scrambled eggs, scrambled eggs puree, breakfast meat, breakfast meat puree, oatmeal, oatmeal puree, cheese omelet, cheese omelet puree). On 1/21/2025 at 9:39 AM, V6 (Director of Culinary Services) states that it should be filled out before the food goes out. V6 states that it is important to know the temperature of the food because they won't know if they need to make corrections and have proper holding temperatures. V6 it's important for the residents' health and avoiding food-related illnesses. On 1/21/2025 at 12:32 PM, V8 (Supervisor for dining) states that there is a steamer on each floor,…

    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 before2025-01-24 · 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 store and label food items in accordance with professional standards for food service safety and follow proper sanitation and food handling. This failure has the potential to affect all residents that receive nutrition from the kitchen. Findings include: On 1/21/2025 at 9:53 AM in the refrigerator with V6 (Director of Culinary Services), was approximately 20 slices of cheese slices dated 1/13 use by 1/20, approximately 15 slices of turkey dated 1/13 use by 1/20, the tail end of cured Italian meat prepared 10/5/2024 with use by 1/10/2025. A Three 5-pound containers of cottage cheese that expired on 1/20/2025. On 1/21/2025 at 10:10 AM in the walk-in freezer with V6 was a blue cheese butter labeled 10/05/2024 use by 1/20/2025, approximately 12 pieces of prepared chicken on a silver tray covered with plastic cover, labeled 10/20/2024 use by 1/1/2025. V6 states these food items should have been discarded. V6 states that she is working on in-servicing the kitchen staff. On 1/21/2025 at 11:26 AM there were several…

    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 before2025-01-24 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to observe proper PPE (Personal Protective Equipment) protocols. This failure has the potential to affect all residents residing in the facility. Findings include: 1. On 1/21/25, at 12:30 PM, observed a sign posted on R19's door frame. The sign had two STOP signs pictured and the CDC (Centers for Disease Control and Prevention) emblem on it. The sign read in part: Contact Precautions. Providers and staff must also: put on gloves before room entry. Put on gown before room entry. V24 (R19 Private Care Giver) was observed inside of R19's room with no PPE (Personal Protective Equipment), gown, gloves worn. On 1/21/25, at 12:33 PM, V24 (R19 Private Care Giver) stated R19 is a two-person assist. V24 cleans R19's face, brushes R19's teeth, puts clothes on R19 and helps the Care Partners-CNA's change R19. V24 works weekdays and sits inside R19's room for companionship and to monitor. V24 stated V24 only wears PPE (Personal Protective Equipment), gown, gloves when V24 changes R19 after a bowel movement. V24 stated a 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 · Ecited before2025-01-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to ensure a safe, hazard free environment for 15 residents residing on the eighth floor of the 29 residing in the facility. Findings include: On 1/21/25, at 9:54 AM, while touring the 8th floor, writer observed four screws on the floor in the hallway. Writer observed two staff members, V20 (Live Enrichment) and V21 (Care Partner/Certified Nursing Assistant-CNA) walk past the screws on the floor without picking them up. On 1/21/25, at 10:07 AM, V22 (Maintenance) was observed picking up the four screws from the floor in the hallway. V22 verified to writer that they are screws. V22 stated I picked them up, so no one has an accident. Someone could step on them and slip and fall. They should not have been on the floor. I don't know who left them there. There have been no calls to me to pick them up. Staff should have picked them up to prevent a hazard. On 1/23/25, at 2:50 PM, V3 (Director of Nursing) stated we keep the supply room with medication and supplies locked. Anything hazardous to the resident is locked,…

    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
Show the remaining 14 citations
  • Potential for harm · D2025-01-24 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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 have a person-centered care plan that is consistent with the resident's current condition, goals, and services for one (R3) resident reviewed in a total sample of 12 residents. Findings include: On 01/21/25, at 12:53 PM, R3 states that she is under hospice care, and she does not know how long she has received hospice services. R3 states she cannot recall what services they provide to her. On 01/23/25, at 10:48 AM, Reviewed R3's active physician order set and documents in part: admitted to Journey Care Hospice 11/16/2024. On 1/23/25, at 1:11 PM, V31 (Licensed Practical Nurse) states R3 is a 2-person assist for ADL (activities of daily living) care, it can take 45-60 minutes to care for because of her behaviors. Sometimes she is very agitated and cursing. She has no wounds. The hospice has provided R3 with the comfort kit. V31 states that hospice comes in every week. Sometimes if there is abnormality and resident is not comfortable, we inform hospice too.…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-24 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow their restorative care policy and provide restorative therapy for one (R18) in a total sample size of 12 resident. Findings include: On 01/21/25, at 1:10 PM, R18 sitting on his wheelchair, in the activity room, and in no apparent distress. R18 unable to be interviewed. R18's left hand constricted. On 01/21/25, at 1:11 PM, V10 (certified nursing assistant) states that R18 tends to flinch his hands and makes fists. On 1/23/2025, at 2:04 PM, via telephone V32 (Licensed Practical Nurse/Minimum Data Set nurse) states that some common Parkinson's disease signs and symptoms can include tremors, they can decline functionally. V32 states that some interventions that can be put in place for a resident with Parkinson's disease can include- monitor for tremors, if they have side effects of the medication, PT/OT (physical therapy/occupational therapy) when we think they need help, doing range of motion for them to maintain the current function…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-24 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to accurately secure controlled substance medications for two residents (R7 and R14) in a sample of 12 reviewed for medication/controlled substance storage. Findings include: 1/21/25, at 10:43 AM, reviewed 8th floor medication cart and medication room with V23 (Licensed Practical Nurse-LPN). Observed V23 open the refrigerator and narcotic lock box without using a key or entering a code or any other unlocking method. Observed the refrigerator to have no locking mechanism. Observed the narcotic lock box inside of the refrigerator to have a coded locking mechanism. V23 verified to writer the narcotic lock box was not locked with the coded locking mechanism. Inside of the unlocked narcotic lock box was Lorazepam Intensol Oral Concentrate 2mg (milligrams) per ml (milliliter) for R7 and R14. 1/21/25, at 11:30 AM, V23 (Licensed Practical Nurse-LPN) stated narcotics should be locked so accessible only to the nurse; to keep them safe. 1/23/25, at 2:50 PM, V3 (Director of Nursing) stated narcotics need to be double locked.…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-02-09 · 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 observations, interviews, and record reviews, the facility failed to a.) ensure kitchen staff wore beard covering in the kitchen during meal preparation, b.) food items were properly labeled, dated, and stored, c.) discard expired foods. These failures have the potential to affect all 31 residents receiving food prepared in the facility's kitchen. Findings include: On 02/06/24 at 9:21 AM, during initial kitchen tour observed V8 (Cook) placing carrots in the steamer and then pulling carrots out of the steamer. V8 had a beard with hair extending past V8's jaw line. V8 was not wearing a beard protector. On 02/06/24 at 9:22 AM, V7 (Director of Culinary Services) stated that everyone entering the kitchen should be wearing a hairnet and beards should also be covered. V7 stated the purpose of the hair nets and beard coverings is so that hair does not fall into the food and cause contamination. V7 saw that V8 was not wearing a beard covering and told V8 to go put a beard covering on. On 02/06/24 at 9:26 AM, V8…

    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 · E2024-02-09 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On 2/06/24 at 12:40 PM, V6 (Certified Nursing Assistant) was assisting R20 for lunch in the 9th floor dining room. R20 received pureed soup, pureed meat, pureed cauliflower, mashed potato, and thickened water. R20 did not receive the pureed macaroni salad and pureed cookie that were listed on the menu. On 2/07/24 at 12:16 PM, V39 (Certified Nursing Assistant) was assisting R20 for lunch in the 9th floor dining room. R20 received pureed soup, pureed biscuit, pureed chicken, pureed green beans, and thickened water. At 12:41 PM, R20 finished eating lunch, and did not get any dessert. R20's clinical records show R20 has a diagnosis of Dementia. R20's Minimum Data Set (MDS) dated [DATE] shows R20 has severely impaired cognitive skills for decision making and has short- and long-term memory problems. R20's physician orders show R20's diet order of pureed diet with honey thickened fluids. Based on observation, interview, and record review the facility failed to serve food as planned on the pureed and mechanical soft…

    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 · E2024-02-09 · tag F0881 — failed to use antibiotics responsibly — pattern
    Implement a program that monitors antibiotic use.
    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 reviews, the facility failed to establish an antibiotic stewardship program that includes a protocol and a system to monitor antibiotic use and failed to use an infection assessment tool to determine if the antibiotic is indicated or needs to be adjusted for four (R15, R23, R25, R27) of four residents reviewed for antibiotic use in a sample of 14. The findings include: R15 health record showed admission date on 1/24/23 with diagnoses not limited to Multiple Sclerosis, Presence of right artificial shoulder joint, Hyperlipidemia, Non ST elevation (NSTEMI) myocardial infarction, Major depressive disorder, Polyneuropathy, Type 2 diabetes mellitus, Hypothyroidism, Morbid obesity, Other specified disorders of bladder, Acute respiratory failure with hypoxia. R23 health record showed admission date on 10/18/23 with diagnoses not limited to Other toxic encephalopathy, Epilepsy, Essential Hypertension, Atrial fibrillation, Gastro-esophageal reflux disease, Hyperlipemia, Obstructive sleep…

    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 · E2024-02-09 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    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 provide eligible residents and/or resident representatives education regarding the benefits and potential side effects of all available pneumococcal vaccinations for 5 residents (R10, R23, R25, R27 and R28), Failed to assess eligibility and offer pneumococcal vaccinations to 4 (R10, R25, R27 and R28) residents and Failed to administer Pneumococcal vaccine for one (R23) resident eligible to receive the vaccine. These failures affect 5 (R10, R23, R25, R27 and R28) of eight residents reviewed for immunization. The findings include: R10 health record showed admission date on 10/15/23, [AGE] years of age with diagnoses not limited to Type 2 Diabetes mellitus, Essential Hypertension, Fracture superior rim of right pubis, Hypothyroidism, History of falling, Depression, Atherosclerotic heart disease, Anemia, Paroxysmal atrial fibrillation. R23 health record showed admission date on 10/18/23, [AGE] years of age with diagnoses not limited to Other toxic…

    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 · D2024-02-09 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the residents were treated with respect and dignity by not passing out meals to residents sitting together at the same time for one (R1) resident and standing over a resident while feeding them affecting one (R2) resident on the total sample of 12 residents reviewed for dining services. Findings include: On 02/06/24 at 12:08 PM, observed R1 and R9 sitting at the same table in the unit dining room. Observed R9 feeding herself lunch and R1 watching R9 eat. R1 did not have anything in front of him to eat. On 02/06/24 at 12:23 PM, observed R9 continuing to eat R9's lunch and R1 still did not have any food in front of him. R1 stated I'm hoping I get served some food soon. I'm waiting. R1 then stated, I haven't gotten my soup yet and then holds up a clean soup spoon to show the surveyor. On 02/06/24 at 12:29 PM, R1 was served soup which R1 began to eat right away with R1's spoon. R9 had completed R9's lunch meal. On 02/06/24 at 12:30 PM,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow wound doctor's recommendations for a resident with an acquired pressure ulcer for 1 (R184) resident. The facility also failed to ensure that appropriate linen is used on an air loss mattress for one (R29) resident who is at risk in developing pressure ulcer. These failures affect two (R29 and R184) residents reviewed for pressure ulcer in a sample of 14. The findings include: 1. R184 health record showed admission date on 7/23/21 with diagnoses not limited to Alzheimer's disease, Hyperlipidemia, Essential Hypertension, Type 2 Diabetes Mellitus, Chronic Kidney Disease, Major Depressive Disorder, Chronic Obstructive Pulmonary Disease, Hypothyroidism, Hyperlipidemia, Dysphagia oropharyngeal phase. On 2/7/24 at 9:47am Wound care observation conducted with V26 (Wound care nurse) assisted by V25 (Certified Nursing Assistant/CNA). Observed R184 lying in bed, alert and verbally responsive, with oxygen inhalation via nasal cannula at 2L/min,…

    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 before2024-02-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On 02/06/24 at 12:30 PM, surveyor observed R14 up in chair, Oxygen tubing and Nebulizer treatment mask were not in a plastic bag when not in use. On 02/07/24 at 12:34 PM, surveyor and V27 (Licensed Practical Nurse) entered R14's room, V27 and surveyor observed R14's Oxygen Nasal Cannula not in a plastic bag and Nebulizer treatment Mask not in a plastic bag. V27 stated having the nebulizer mask and oxygen nasal cannula out makes R14 at risk for breathing in germs like bacteria. The oxygen nasal cannula and mask should have been contained in a plastic bag when not in use. On 2/8/24 at 9:30 AM, V2 (Director of Nursing) stated, it is V2's expectation that nurses will keep oxygen nasal cannula tubing and nebulizer treatment mask in a plastic bag when not in use to maintain good hygiene and prevent infection. R14 Minimum Data Set, dated [DATE] shows R14 is cognitively intact. R14 Physician Order Sheet (POS) with active orders as of 2/6/24 shows an order for Pulmicort 1 mg/2ml suspension for nebulization inhalation…

    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 before2024-02-09 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to follow their policy and procedure to ensure medications were stored safely and securely for one (R4) resident out of 14 residents reviewed for medication storage in a final sample or 14. Findings Include: On 2/06/24 at 11:19 AM, R4 was sitting on R4's wheelchair in R4's room with V35 (R4's Caregiver) at bedside. Surveyor noted a nebulizer machine and two ampules of Ipratropium-Albuterol solutions on top of R4's nightstand. R4 stated that R4 has not received R4's nebulizer treatment yet. V35 stated that R4 just came back from the hospital for Pneumonia. R4 stated that the nebulizer treatment helps R4 breaths better. At 11:40 AM, V5 (Registered Nurse) stated that there is no resident in the unit that is self-administered with medications. V5 stated that all residents' medications should be kept inside the medication cart and not at resident's bed side. On 2/8/24 at 9:27 AM, V2 (Director of Nursing) stated that all medications should 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-09 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to prepare and serve mechanical soft food at the appropriate texture. This failure affected 1 (R184) of 4 residents reviewed for mechanical soft diet prepared in the facility's kitchen, in a total sample of 31 residents. Findings Include: R184's diagnoses includes but not limited to Dysphagia Oral Phase, Dysphagia Oropharyngeal Phase, Alzheimer's Disease, Unspecified Dementia. R184's Physician Orders for 02/07/24 document diet order is mechanical soft with nectar thick liquids ordered 01/21/23. R184's MDS (Minimum Data Set) from 12/24/23 BIMS (Brief Interview for Mental Status) was 03 out of 15 indicating severely impaired cognition. R184's nutrition care plan documents in part, R184 is at nutrition risk related to altered texture diet for dysphagia. R184's Speech Language Pathology Evaluation and Plan of Care dated 11/02/22 documents in part, R184's diet was downgraded to mechanical soft, nectar thick liquids following MBSS (Modified Barium Swallow Study) and resident continues to be at risk for aspiration…

    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 · D2024-02-09 · tag F0813 — isolated
    Have a policy regarding use and storage of foods brought to residents by family and other visitors.
    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 facility policy for personal refrigerators by not keeping a temperature log to ensure refrigerator is at proper temperature, labeling items with a date, monitoring food for quality for potential concerns and disposal of items from resident's personal refrigerators for two (R8, R17) residents reviewed in the sample of 4 for safe personal food storage. Findings include: On 02/06/24 at 11:20 AM, observed in R17's personal refrigerator in R17's room undated plastic container full of diced cheese chunks and the chucks of cheese were covered in multiple spots of fuzzy green circles. Also, observed an undated container of what appeared to be chicken and potatoes. Did not observe a thermometer inside R17's refrigerator or a temperature log on or near R17's personal refrigerator. On 02/06/24 at 11:23 AM, R17 stated that no one monitors her refrigerator and that they should be dating the items in there because she does not know what is inside it. On 02/06/24 at 11:26 AM, V11 (Certified Nursing Assistant) 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2026-03-05 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record review, facility failed to follow their policy and federal regulations and failed to ensure the Daily Nurse Staffing Posting information forms were posted daily in a prominent place readily accessible to residents, staff and visitors. These failures have the potential to affect all 30 residents residing in the facility. Findings include:On 3/2/2026 at 9:31 AM, facility presented a census of 30 residents living at the 8th and the 9th floor units.On 3/2/2026 at 10:30 AM, surveyor observed main lobby of the facility and the 8th floor unit. Observed nursing station, posting boards at the nurse's station and announcements and information posted on the walls of the 8th floor unit. The Daily Nurse Staffing Posting sheet was not observed displayed prominently anywhere on the 8th floor unit or main lobby of the facility.On 3/3/2026 between 11:40AM and 11:57 AM, surveyor observed main lobby , 8th floor unit and 9th floor unit of the facility and did not observe the Daily Nurse Staffing Posting sheets prominently displayed on any surface 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.

    Nursing and Physician Services 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 / managerTypeRoleSince
BENSEN, KATEIndividualCORPORATE DIRECTORsince 01/01/2022
BHANDARI, JUSTINIndividualCORPORATE DIRECTORsince 01/01/2020
BOIKE, KIMIndividualCORPORATE DIRECTORsince 04/01/2022
BRAIER, CHRISIndividualCORPORATE DIRECTORsince 07/01/2022
CAMPBELL, TOYAIndividualCORPORATE DIRECTORsince 07/01/2024
DAW, SHARIIndividualCORPORATE DIRECTORsince 07/01/2024
FARMER, NICHOLASIndividualCORPORATE DIRECTORsince 10/01/2024
HOWE, JONATHANIndividualCORPORATE DIRECTORsince 01/01/2025
MCKEE, LAURAIndividualCORPORATE DIRECTORsince 01/01/2018
SHIELDS, JORDANIndividualCORPORATE DIRECTORsince 08/01/2018
SMITH, TONIIndividualCORPORATE DIRECTORsince 01/01/2024
TAYLOR, JACKIEIndividualCORPORATE DIRECTORsince 04/01/2024
WACKERLE, FREDIndividualCORPORATE DIRECTORsince 04/01/2017
WETMORE, CAROLIndividualCORPORATE DIRECTORsince 04/01/2022
GEIGLER, NADIAIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 01/27/2017
KEEGAN, ERIKAIndividualCORPORATE OFFICERsince 10/16/2023
ZIELINSKI, RICHARDIndividualCORPORATE OFFICERsince 12/20/2021
DITTMER, HELENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/06/2026
MIZUNO, ERICIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2016

CMS files one row per role, so the 22 rows in the source record cover these 19 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.

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.

$4.4M
Net patient revenuemost recent cost report
Operating marginrevenue minus expenses
−$122K
Related-party expense-0% of expenses
Who pays — share of resident-days
Medicaid 0%Medicare 16%Other / private 84%

This home reported −$122K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$2,630per resident / day
operating cost
$79,945per month
≈ monthly operating cost
$376per 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 146165. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-05, 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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