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Astoria Place Living & Rehab

6300 North California Avenue, Chicago, IL 60659 · For profit - Limited Liability company · 164 certified beds · (773) 973-1900 Medicare & Medicaid certified

Call the home — (773) 973-1900 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Nov 20242 actual-harm citations$4,784 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Nov 2024
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $4,784 in federal fines (most recent 2025-03-27)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its payroll-based staffing rating is low (2/5)
  • about 19% 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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 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

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
6350 N Fairfield Ave · (773) 508-4800 · Call to confirm hours
Pharmacy
2763 W Devon Ave · (773) 338-7171 · Call to confirm hours
Grocery
Aldi<0.1 mi
6220 N California Ave · (855) 955-2534 · Call to confirm hours
Park
2650 W Peterson Ave · (773) 761-0582 · Typically dawn to dusk
Place of worship
6326 N Washtenaw Ave · (773) 262-6600

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
Short-stay residentsrehab / post-hospital 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased4.3%13.4%15.4%better
Long-stay residents who lose too much weight6.8%6.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.6%0.9%0.9%better
Long-stay residents with a urinary tract infection0.2%1.5%2.0%better
Long-stay residents with depressive symptoms96.1%54.2%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.6%3.1%3.3%better
Long-stay residents whose ability to walk worsened5.7%14.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication8.0%18.3%18.9%better
Long-stay residents given the seasonal flu vaccine89.9%91.8%95.3%typical
Long-stay residents with pressure ulcers4.9%4.8%4.7%typical
Long-stay residents with worsening bladder/bowel control28.1%20.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table10.5%21.7%17.1%better
Short-stay residents who newly got an antipsychotic medication1.3%2.2%1.4%typical
Short-stay residents given the seasonal flu vaccine88.6%63.1%79.4%better
Short-stay residents rehospitalized after admission30.9%26.1%22.6%worse
Short-stay residents with an outpatient ER visit16.4%13.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.432.021.67better
Long-stay outpatient ER visits per 1,000 resident days1.382.221.80better

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

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

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

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

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

57.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 96 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

57.9%U.S. median 51.5%
Got home and stayed home
8.9%U.S. median 10.7%
Went back to hospital
73.6%U.S. median 56.6%
Met the expected recovery
0.18U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.06hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 73.6% 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 0.18 therapist hours per resident per day in 2026Q1 — more than 17% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 30% 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 SNF57.9%CMS range 48.2–70.351.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.9%CMS range 6.2–12.410.7%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 discharge73.6%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 discharge67.9%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge50.9%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 identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting97.8%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 stay1.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.6%CMS range 3.9–12.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.311.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.86
RN hours/ resident / day
0.41
LPN hours/ resident / day
1.82
Aide hours/ resident / day
3.09
Total nurse hours/ resident / day
0.92
RN hoursweekends
38.4%
Total nursing turnover
24.1%
RN turnover

How full it usually is: this home is certified for 164 beds and averages 153.9 residents a day — about 94% occupied, or roughly 10 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.09 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.86 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.82 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.98 hrs/resident/day on weekends vs 3.14 on weekdays — 5% thinner on weekends. RN hours go from 0.84 to 0.92 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 38% is about the same as the national median of 45%.

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

Inspection trend

8
deficiencies at the latest standard inspection (2024-11-22)
9
at the previous standard inspection (2023-12-13)

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.

32 citations, most serious first. The 12 most serious are shown; the remaining 20 are one tap away and print in full.

  • Actual harm · Gcited before2025-04-22 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observation, interview, and record review the facility failed to follow facility polices and procedures, failed to ensure that residents are assessed for signs/symptoms of pain, failed to obtain physician orders, failed to follow physician orders, and failed to ensure that physician orders are transcribed on the MAR (Medication Administration Record). The facility also failed to administer pain medication timely to three of four residents (R1,R2, R4) reviewed for pain. These failures resulted in R2 crying due to experiencing excruciating pain. Findings include: 1. R2 was admitted on [DATE] (9 months ago) with cervical radiculopathy (pinched or irritated nerve in the neck causing pain radiating into the chest or arm). R2's (7/12/24) care plan states resident is at risk for pain related to cervical radiculitis, interventions: monitor and record/report to Nurse any signs/symptoms of non-verbal pain. Resident will be able to tell you how much pain is experienced and tell you what increases or alleviates…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2025-03-27 · 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 interviews and record review, the facility failed to ensure the safety of one resident (R3) as two Certified Nurse Assistants prepared to transfer resident from chair to bed. This failure resulted in R3 falling and sustaining a laceration to the forehead requiring hospitalization and stitches. Findings include: R3 is [AGE] year old with diagnosis including but not limited to: history of falling, presence of artificial right hip joint, other osteoporosis and fracture of unspecified part of right femur. During investigation on 3/24/25 at 12:53 PM, R3 was observed lying in bed with a scar on her forehead. On 3/24/25 at 12:53 PM, V7 (CNA/ Certified Nurse Assistant) said that R3 had fallen from her geri-chair (geriatric chair) while she (V7) and V6 (CNA) were preparing to transfer R3 to her bed. V7 said, V6 (CNA) and I were working together to transfer her (R3) because she is a total care patient. R3 was sitting up in her chair by the bed and I went to go and get the mechanical lift. V6 was standing on the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-26 · 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 interview and record review the facility failed to promote wound healing in one resident (R3); failed to follow their policy to prevent new pressure ulcers from developing in two residents (R1 and R3) and failed to document skin monitoring and/or frequency to observe for skin impairments. This failure resulted in R1 and R3 developing new unstageable pressure ulcers. Findings include: 1. R1 diagnosis include but are not limited to Diabetes, Anemia, Hypertension, Hyperlipidemia, Schizoaffect Disorder, Bilateral Hearing Loss, and has impaired mobility. R1 was transferred to the hospital on [DATE] and did not return to the facility. R1's Wound Assessment Report dated 12/9/25 Left buttock, incontinence associated dermatitis (IAD), partial thickness, acquired in house on 12/8/25, New, 100% epithelial. Cleanse and apply bordered foam daily. R1's Skin Alteration Nursing Evaluation/ dated 12/9/25 notes NEW skin alteration. Left buttock, Other, Length 2.0 x With 1.0, Stage N/A. [This evaluation has no mention of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-26 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to practice infection control measures during a wound care dressing change on a resident. This failure affected 1 (R2) of 3 residents reviewed for wound care. Findings include:On 2/24/2026 at 10:45 am, V3 (Wound Care Coordinator) began preparing wound care supplies; without performing hand washing or hand sanitizing measures and opening/touching the treatment cart drawers; opened the surgical drape touching with her (V3's) bare hands; touched her glasses and with same hand and began typing on her laptop reading the wound care order; opened another drawer and removed a stack of gauze with her bare hands; and V3 used hand sanitizer and removed other supplies from the cart.On 2/24/2025 at 10:48 am, V3 stated she (V3) should practice handwashing and infection control practices before, between, and after wound care. V3 verified using hand sanitizer after opening the surgical drape and preparing other wound care supplies. V3 stated the purpose of infection control practices such as hand washing/sanitizing is to prevent…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-10-28 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their abuse prohibition policy by failing to immediately report an allegation of staff to resident sexual abuse to the abuse the coordinator. The facility also failed to report suspicion of a crime to local law enforcement. These failures affect 1 resident (R1) of 5 reviewed for abuse.Findings include:R1 was admitted to the facility on [DATE] for therapy due to left knee surgery. R1's medical diagnoses include mood disorder, schizoaffective disorder, bipolar disorder, major depressive disorder and generalized anxiety disorder. On 10/23/2025 at 08:16 AM, V3 (Community Case Worker/Social Worker) stated that he worked with R1 before R1 was admitted in the facility as her social worker. V3 stated that R1 was admitted in the facility on the evening of 10/21/2025. During that time V5 (Certified Nursing Assistant) gave her a sponge bath feeling her body and her breast leaning tried to kiss R1, Making pass to go to bed. V3 stated that R1 told V5, 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-12 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to ensure that a resident's medications were documented as administered, as ordered by the physician. This failure affects one resident (R1) out of three residents reviewed for quality of care.Findings include:On 08/12/2025 at 12:30pm V2 (DON/Director of Nursing) presented R1's MARs (medication administration records) to the surveyor, which were reviewed. There were missing entries of nurses' signatures/initials or codes on the MARs for June 2025 (6/1/2025 to 6/30/2025).R1's diagnoses include Dementia, Asthma, Bipolar Disorder, Chronic Diastolic Heart Failure, and Major Depressive Disorder.There were missing entries of nurses' signatures/initials or codes on R1's medication administration record for the following medications, dates, and times:On 06/08/2025 at 6:00am Levothyroxine Sodium (Hormone) 50 mcg (microgram) tablet- Give 1 Tablet by mouth in the morning.On 06/08/2025 at 6:00am Pantoprazole Sodium (Antiulcer) Oral Tablet Delayed Release 40 mg (milligrams)- Give 1 tablet by mouth in the morning.On 06/08/2025 at 6:00am…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-28 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    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 pain management in accordance with the resident's comprehensive care plan, the resident's goals for care and preferences. This failure affects one (R1) resident of four residents reviewed for pain in the sample of seven. Findings include: R1's current face sheet documents R1 is a [AGE] year-old individual admitted to the facility on [DATE] and has diagnoses not limited to: multiple sclerosis, encounter for palliative care, malignant neoplasm of colon, unspecified, unspecified displaced fracture of second cervical vertebra, subsequent encounter for fracture with routine healing. R1's MDS/Minimum Data Set, dated [DATE] documents that R1 has a BIMS/Brief Interview for Mental Status score of 15/15, indicating that R1 is cognitively intact. R1's physician order set documents in part R1 has an active order for HYDROmorphone HCl (Hydrochloride) Tablet 4 MG (milligrams) Give 1.5 tablet by mouth every 6 hours for Pain since 02/25/2025. R1's physician…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-22 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based upon interview and record review the facility failed to follow policy procedures, failed to ensure that floor stock medication was available, failed to ensure that floor stock medication was transcribed on the MAR (Medication Administration Record), failed to ensure that prescribed medication was transcribed correctly, and/or failed to administer medication as ordered for four of four residents (R1, R2, R3, R4) reviewed for medication administration. Findings include: 1. R1's diagnoses include dislocation of right hip, pain in left leg, and sciatica right side. R1 was discharged from the facility on 4/10/25. R1's (3/20/25) care plan includes risk for pain, intervention: provide analgesic as ordered. R1's (3/24/25) POS (Physician Order Sheets) includes Lidocaine Patch 4% apply to right hip in the morning for pain. On 4/15/25 at 3:11pm, V6 (Registered Nurse) affirmed that the 4% lidocaine patch is a facility house stock (over the counter) medication. On 4/16/25 at 2:46pm, surveyor inquired about the facility (house stock) 4% Lidocaine patch availability V7 (Central Supply)…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-11-22 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to ensure prepared foods stored in the walk-in cooler were properly dated, labeled and discarded on the use by date. These failures have the potential to affect 154 residents in the facility who are receive an oral diet. Findings Include: On 11/19/24 at 9:08 AM during the initial kitchen tour in the kitchen with V23 (Cook), there was a food cart with trays of prepared foods such as ham sandwich, vanilla pudding, chocolate pudding, cups of fruits, and pitchers of lemonade. The prepared foods on the tray had no labels when they were prepared. The plastic cover covering the food cart had no label. V23 called V22 (Dietary Aide) and entered the main cooler. V22 stated that the plastic cover should have a date labeled when they were made to know when the food should be discarded. Surveyor and V22 also found a bag of opened grated parmesan cheese with the label that reads prepared date 11/9/24 and used by 11/16/24 (no manufacturer's expiration date noted). V22 stated prepared date is the same as opened date on the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-11-22 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    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 reviews, the facility failed to follow R95 and R110's care plans by not administering the ordered oxygen flow rates, label R40's oxygen tubing, store R86's oxygen tubing while not in use and have oxygen signage for R399 for five out of a total sample of 31 residents. Findings include: R40's admission Record documents in part a primary diagnosis of chronic respiratory failure with hypoxia (low oxygen content in the blood). R40's Order Summary Report documents in part orders to change oxygen tubing every night shift every [Sunday] for infection control (active 10/03/2024) and oxygen continuous 2 [liters per minute] via nasal cannula every shift (active 10/03/2024). On 11/19/2024 at 11:18 AM, R40 was sitting in the common/dining room reading. R40 received 2 liters of oxygen via nasal cannula. The nasal cannula was not labeled and R40 did not recall the last time staff changed it. On 11/20/2024 at 10:42 AM, V2 (Director of Nursing) stated the nasal cannula 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-11-22 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to properly date opened multi-dose respiratory inhalers and nasal spray, failed to store unopened multi-dose eye drop solution and discard expired multi dose medications for 6 residents (R38, R58, R75, R103, R111, R125) from 3 of 6 medication carts reviewed for medication storage and labeling. Findings include: R38's admission record showed admission date on [DATE] with diagnoses including Type 2 diabetes mellitus with unspecified diabetic retinopathy, Primary open-angle glaucoma bilateral, Age-related nuclear cataract bilateral. R58's admission record showed admission date on [DATE] with diagnoses including Diabetes mellitus, Legal blindness, Chronic obstructive pulmonary disease, Essential (primary) hypertension. R75's admission record showed admission date on [DATE] with diagnoses including Other sequelae of nontraumatic intracerebral hemorrhage, Thyrotoxicosis, Essential (primary) Chronic obstructive pulmonary disease. R103's admission…

    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 · Ecited before2024-11-22 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to follow their infection prevention and control policy by failing to don proper personal protective equipment, failing to handle soiled linen properly and failing to perform hand hygiene after handling soiled linen. These failures have the potential to affect all 45 residents residing on the one residental floor at the facility. Findings include: On 11/19/24 at 11:45 AM, there was orange signage for Enhanced Barrier Precautions (EBP) posted on the outside of R77's door. On 11/19/24 at 11:47 AM, V12 (Certified Nursing Assistant) viewed the orange signage for Enhanced Barrier Precautions posted outside R77's room and stated that sign tells V12 that R77 is on Enhanced Barrier Precautions which means that when V12 goes into R77's room to provide direct resident care V12 wears a gown and gloves. V12 stated if V12 is only going into the room to drop something off such as R77's food tray and V12 is not going to touch the resident then V12 only has to use hand sanitizing solution before and after entering the room, 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 20 citations
  • Potential for harm · D2024-11-22 · 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

    Based on observation, interview, and record review, the facility failed to provide privacy and promote dignity for one of one resident [R105] reviewed for urinary catheter use on the sample list of 31. Findings included: On 11/19/24 at 10:24 AM, R105's urinary catheter bag was hanging on the side of R105's bed, half filled with urine and visible from the hallway. The urinary catheter bag did not have a protective cover over the bag. R105 stated the [R105] is on the urinary catheter bag because of [R105's] wound. On 11/20/24 at 10:33 AM, interviewed V2 (Director of Nursing) and stated that urinary catheter bag placement should not be facing the door, and if it's facing the door, it should be inside of a bag for privacy. V2 stated that if the urinary catheter bag is exposed, it can potentially cause a dignity issue. R105's physician orders document in part: Indwelling Catheter Type: (urinary) Catheter Size: 16 FR, 10 cc (cubic centimeter) balloon Reason for use: Neurogenic Bladder (ordered 10/27/24). The facility's Privacy and Dignity policy dated 8/16/24 documents in part: It is the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-22 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a low air loss mattress device was on the correct weight setting for one dependent resident (R105) of two residents with pressure ulcers on a sample list of 31 residents. Findings Include: R105's clinical records show an admission date of 10/27/24 with included diagnoses not limited to Multiple Sclerosis and Stage 4 Pressure Ulcer. R105's physician orders read: Low Air Loss (LAL) Mattress ordered on 10/27/24. R105's skin care plan date initiated on 10/27/24 reads in part: R105 has a pressure injury on the sacral area with one intervention that reads, Check air mattress if functioning properly every shift and prn [as needed]. R105's weight shows 180 lbs dated 11/15/24. R105's Skin Risk assessment dated [DATE] shows a score of 10 (High Risk in developing a pressure ulcer). On 11/19/24 at 10:24 AM, R105's lying in bed alert and able to verbalize needs. Surveyor observed R105's low air loss mattress weight setting was set to 180 pounds…

    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 before2024-11-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to distinguish between a behavior slide versus a fall, and failed to follow their fall occurrence policy for one [R119] resident reviewed for falls on the sample list of 31 residents. Findings include: R119 's clinical record indicates the follow in part; R119 was admitted the medical diagnosis of cerebral infarction with hemiplegia and hemiparesis affecting left dominant side, coronary angioplasty, ventricular tachycardia, cardiac implants, major depressive disorder, generalized weakness, anxiety, and alcohol abuse with withdrawal. R119's Minimum Data Set [MDS] section [ C] Brief interview Mental Status he scored [04] indicates R119 is moderately impaired. R119's care plan indicates the following: 8/9/24- R119 demonstrate cognitive impairment related to psychiatric disorder, history of substance abuse, impaired decision making, poor logic and poor ability to understand cause and effect. Poor judgement and awareness. 6/17/24- R119 has an impaired mobility. 8/6/23- R119 is at high risk for falls related to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-22 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure medication was administered and not left at bedside for 1 (R113) resident reviewed for medication administration in a sample of 31. Findings include: R113's admission record showed admission date on 6/24/2023 with diagnoses including Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Occlusion and stenosis of left carotid artery, Other sequelae of cerebral infarction, Other specified arthritis multiple sites, Deficiency of other vitamins, Thyrotoxicosis, Nicotine dependence cigarettes, Chronic obstructive pulmonary disease, Essential (primary) hypertension, Other psychoactive substance abuse, Chronic viral hepatitis C. On 11/19/24 at 10:31 AM Observed R113 sitting on the side of the bed, alert and verbally responsive. Observed 1 white round pill inside the medication clear cup at bedside table. R113 stated he does not know what medication it was. Requested V5 (Registered Nurse/RN) in R113's room and said it could be a thyroid medication from 11-7 shift nurse. She…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-04 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 affirm the rights of a resident to be free from abuse. This failure affects one (R1) of three residents reviewed for abuse. Findings Include: R1's electronic health records (EHR) documents R1 was initially admitted to the facility on [DATE] with listed diagnoses not limited to but including Unspecified Dementia, Alzheimer's Disease, Dysphagia, Moderate Protein Calorie Malnutrition, Anorexia, Chronic Kidney Disease Stage 4, Repeated Falls, Type 2 Diabetes Mellitus. R1 was admitted under hospice services on 05/04/23 for end-of-life support. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has severely impaired cognition and requires substantial/maximal assistance with Activities of Daily Living (ADLs). R2's EHR documents R2 was initial admitted to the facility on [DATE] with listed diagnoses not limited to but including Alzheimer's Disease Late Onset, Dysarthria and Anarthria, Major Depressive Disorder, Unspecified Mood Affective Disorder, Alcohol…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-12-13 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose 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 lids on the outside dumpsters were closed and maintained in a sanitary condition to prevent the harborage and feeding of rodents and pests. This failure has the potential to affect all 150 residents in the facility. Findings include: On 12/10/23 at 11:30am after the entrance conference, the facility census was 150 as reported by V1 (Assistant Administrator). On 12/10/23 at 9.20am, two outside dumpsters were observed. Each dumpster had a lid attached. The larger 3 compartment dumpster had the middle lid flipped to the back of the dumpster, and the smaller dumpster also was left open. On 12/10/23 at 10:45am immediately after observation of the kitchen with V16 (Cook), the dumpsters were still in the same conditions. At this time, V16 was asked about why the dumpsters were left open. V16 stated that he believes that the housekeeping staff left the dumpsters open because housekeeping also dumps garbage there. On 12/11/23/at 10:50am, the smaller dumpster had the lid partially covering the dumpster,…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-12-13 · 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

    Based on observation, interview and record review, the facility failed to ensure that medications were secured in a locked medication and treatment cart which has the potential to affect 48 residents on the second floor and 52 residents on the third floor. Findings include: On 12/11/23 at 9:17 am, during the medication pass observation, V9 (Agency LPN) observed standing in front of medication cart A. V9 pulls out the medication cart keys out of V9's scrubs pocket, and a clear, plastic squeeze vial of nebulizer medication falls out of V9's pocket onto the floor. V9 then picked up the nebulizer medication vial (Ipratropium-Albuterol Solution 0.5-2.5 milligrams/3 milliliters) off the floor and placed it on top of medication cart A. V9 asked this surveyor where to show this surveyor the prepared medications, and this surveyor instructed V9 to perform V9's own process and that this surveyor will check the container that the medication is dispensed out of after V9 removes the medications. V9 next removes and prepares R69's medications from medication cart A except the Vitamin D 12 100 mg.…

    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 · D2023-12-13 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents have a quiet and home like environment while sleeping at night without being disturbed by loud noises from another resident. This failure affected 2 residents (R57 and R115), reviewed for resident's rights to enjoy a quiet homelike environment, in a total sample of 50 residents. Findings include: On 12/11/2023 at 11:00am, during the Resident Council group interview, R57 and R115 stated, R40 yells and screams all day and night. R57 and R115 stated, R40's yelling and screaming is preventing them from having a quiet and peaceful sleep at night. On 12/11/23 at 2:17pm, surveyor and V8 (Licensed Practical Nurse, LPN) at the 3rd floor nurses station could hear R40's audible noises from R40's room down the hallway. When asked how often R40 was loudly audible, V8 stated, R40 has lately been more often. When asked how is V8 ensuring other residents on the floor were ensured their rights to a quiet environment. V8 stated, V8 will redirect 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-13 · 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 2. On 12/10/2023 at 11:36am, R198 was lying on a Low Air Loss (LAL) mattress. The setting of R198's LAL mattress observed at 230 pounds. On 12/10/2023 at 12:30 pm, this surveyor inquired with R198 about R198's weight. R198 stated, I (R198) weigh about 120 pounds. R198's admission Record documents, in part, R198's diagnoses including but not limited to: hypertension, hyperparathyroidism, chronic kidney disease, Hemiplegia and Hemiparesis. R198's Minimum Data Set (MDS), dated [DATE], documents, in part, R198's Brief Interview for Mental Status (BIMS) score is 09, which indicates R198 is moderately cognitively intact. R198's (printed date: 12/12/2023) Monthly Weight Report documented, in part December 114.0 lbs (pounds). R198's Patient Risk Profile, dated 12/07/2023, documents a Braden score of 13 which shows R198 is at moderate risk for developing a pressure ulcer injury. R198's Care Plan, with initiated on 4/24/23 with last review completed on 11/6/23, documents, in part, a focus of (R198) is at risk 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-13 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to ensure the G-tube feeding was labeled for one resident (R103). This has the potential to affect all residents receiving enteral feeding on the 2nd floor. Findings: R103 has a diagnosis of Sequelae of Cerebral Infarction, Chronic Respiratory Failure with Hypoxia, Metabolic Encephalopathy, Severe Protein-Calorie Malnutrition, Hypertension, Hemiplegia and Hemiparesis following Nontraumatic Intracerebral Hemorrhage, Dysphagia, Oropharyngeal Phase, Aphasia and Gastrostomy. R103's Order Summary Report with active orders as of 12/12/2023 documents Enteral Feed Order every shift Enteral Feeding: G-tube Nutren 2.0 at rate of 50ml for 21 hours to reach 1050ml. On 12/10/2023 at 10:50am surveyor observed R103's g-tube feeding running with no patient identifiers on the bag. On 12/10/2023 at about 11:00am V7 (LPN) stated, feedings are changed every 24 hours and should be labeled with the resident's name, rate, start and stop date and there is no label on R103 feeding or the information section is not completed. On 12/12/2023…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-13 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    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 label with date: the bag of intravenous (IV) fluids being infused, the IV site on the resident's left wrist, and the IV tubing, during administration of intravenous fluids to a resident. This failure affected one resident (R138), reviewed for IV fluids administration, in a total sample of 50 residents. Findings include: On 12/10/23 at 10:50am during observation of residents on the fourth floor, R138 was observed awake in bed with IV(Intravenous) fluids, 1000mL IV Fluid Bag of 5% Dextrose in 0.45% Sodium Chloride infusing at 70 ml (milliliters) per hour. The IV bag was half infused but there was no date or label to show when it was hung up, no label or date on the left wrist IV site, and no label/date on the IV tubing. R138 told the surveyor that the IV was inserted 5 days ago. On 12/10/23 at 12:05pm, R138's IV fluid was running and there was no date on the IV bag, IV tubing and the IV site. On 12/10/23 at 11:20am, V18(Psychotropic Nurse) stated, I helped with putting in the IV and it's not up to 5 days; it was…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-13 · 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 observation, interview and record review, the facility failed to ensure that physician ordered oxygen therapy was provided to a resident which affected one resident (R21) in the sample of 50 residents when reviewed for oxygen therapy. Findings include: On 12/11/23 at 10:20 am, R21 observed in bed with nasal cannula oxygen tubing noted on R21's face with the prongs outside of R21's nares above nose. R21's nasal cannula tubing observed disconnected from the humidifier bottle on the concentrator oxygen machine and laying on the floor next to R21's bed. R21's oxygen level is set at 2 liters per minute (L/min) on the oxygen concentrator machine. On 12/11/23 at 10:26 am, this surveyor requested V8 (Licensed Practical Nurse, LPN) to come see R21. This surveyor showed V8 that R21's oxygen is outside R21's nares on R21's face and is disconnected from the concentrator on the floor. V8 stated, sometimes, R21 will pull off the nasal cannula oxygen. V8 stated that the night nurse changes the oxygen tubing at 6:00 am…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-13 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an accurate account of controlled substance record for two residents (R28 and R42) reviewed for controlled substance in a sample of 50 residents. Findings include: On 12/10/23 at 11:37 am, V26 (Registered Nurse) review of 2nd floor team 2 medication cart. (room [ROOM NUMBER]-214, 216-229, excluding 211, 213 and 215). On 12/10/23 at 11:40 am, R28's controlled drug administration record documented, Hydrocodone-APAP 10/325 mg (Milligram) count of 27, observed 25 hydrocodone- APAP 10/325 mg on the medication bingo card. On 12/10/23 at 11:42 am, R42's controlled drug administration record documented Alprazolam 0.5 mg count of 24, observed 23 Alprazolam 0.5 mg on the medication bingo card. On 12/10/23 at 11:45 am, R42's controlled drug administration record documented Hydrocodone-APAP 5/325 mg count of 10, observed 9 Hydrocodone APAP 5/325 mg on the mediation bingo card. On 12/10/23 at 11:46 am, V26 (RN) stated, the night shift 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-13 · 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 properly log refrigerator temperatures for two residents (R 47 and R110); and failed to discard expired food from a resident (R110) refrigerator. These failures affected R47 and R110 in the sample of 50 residents. Findings include: R47 has a diagnosis which includes but not limited to vitamin D deficiency, corticobasal degeneration, anemia, dysphagia oropharyngeal phase, acute respiratory failure with hypoxia, mixed hyperlipidemia, malignant neoplasm of prostate, anxiety, and spinal stenosis. R47's Brief Interview for Mental Status (BIMS) dated 09/30/23 documents that R47 has a BIMS score of 00 which indicates that R47 is cognitively impaired. During this interview R47 was able to answer questions appropriately. R110 has a diagnosis which includes but not limited to hypertensive heart disease without failure, seborrhea capitis, major depressive disorder single episode, generalized anxiety disorder, vitamin D deficiency, mixed hyperlipidemia, other insomnia not due to a substance or known physiological…

    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 before2023-01-06 · 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 serve meals with an appetizing temperature by providing food with temperatures below 135 degrees F for 2 residents (R37, R104) reviewed in a sample of 47. This deficient practice has the potential to affect all 135 who receive their meals from the kitchen. Finding Include: On 01/03/2022 at 11:08 am, R104 stated, The hot meals that we are served at lunch and dinner time are often cold. It's hard to eat the meal and enjoy it when it's cold. Many times, I could not eat and enjoy the meals because it's cold and not cooked properly. On several occasions when they served us broccoli at mealtimes, the tip of the broccoli was refrigerator cold, and I could not eat it. On 01/03/2022 at 11:11 am, R37 stated, The facility has a problem with serving warm meals. The lunch and dinner that we get are often served cold. On many occasions the broccoli was not only cold but still frozen and not even cooked properly. I don't like eating my meals cold because…

    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 · E2023-01-06 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their call light protocol to ensure dependent residents have accessibility to the call light at all times for four [R50, R70, R95, R100] of 4 residents reviewed for call lights in a sample of 28 residents. Findings include, On 1/3/23 10:30 AM, observed R95 resting in bed and the call light laying in the dresser drawer. On 1/3/23 V4 [Certified Nurse Assistant] stated, R95 is able to use the call light. The call light should be attached to the bedding, not in the dresser drawer, so R95 can call for assistance as needed. Reviewed R95's medical record document in part; admitted on [DATE], with the primary diagnosis of Hemiplegia affection right dominant side. Care plan dated 7/12/22 read- Place R95's call light within assessable reach. Encourage R95 to use call light for assistance. Please make sure that R95's call light is within reach and encourage R95 to use it for assistance as needed. On 1/3/23 at 10:44 AM, observed R70 resting in…

    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 · Ecited before2023-01-06 · 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

    Based on observation, interview and record review, the facility failed to follow their policy on (a) controlled medication count for 1 resident (R16), (b) failed to securely store controlled medication for 1 resident (R8) and (C) failed to dispose expired medications in 2 of 3 medication carts reviewed. This deficiency has the potential of affecting all 90 residents residing on the 2nd and 4th floors. Findings include: On 1/3/2023 at 12:31 pm on the 3rd floor, during inspection of 3rd floor side B medication cart with V9 (Licensed Practical Nurse-LPN), house Stock medication Folic acid 400mg was observed with manufacture's expiration date of 7/22. V9 said expired medications should not be in the medication cart and should be discarded to prevent being given to residents. V9 said expired medications, if given to residents can cause adverse effects on residents' health. On 1/3/2023 at 12:52 pm, during medication room inspection on fourth floor, V10 (Registered Nurse-RN) and surveyor observed the medication fridge with a metal latch on the side without a lock or key. V10 pulled open…

    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 · Ecited before2023-01-06 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to follow their infection control procedures during an outbreak of COVID-19 by not having the proper isolation signage outside of COVID-19 positive residents and performing proper hand hygiene when doffing gloves from a COVID-19 positive room for 4 (R13, R192, R99 and R129) of 7 residents reviewed for transmission-based precautions in a total sample of 28 residents. Findings include: On 01/03/2023 at 12:13 PM, surveyor observed a PPE (Personal Protective Equipment) bin outside R13 and R192' door. There were no transmission-based precautions on their door. Surveyor asked V14 (Agency Certified Nurse Aide) if R13 and R192 are on isolation. V14 stated [V14] didn't know. Surveyor reviewed R192's POS (Physician Order Sheets). POS documents in part: Maintain at all times: Strict contact/droplet isolation precautions due to an active infection COVID 19. At 2:55 PM, surveyor re-checked R13 and R192's room. There were no transmission-based precautions on their door or inside the PPE bin outside their door. At 4:30 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-06 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to follow their policy on Self Medication Administration for 1 resident (R76) reviewed for self-medication administration in a sample of 28 residents reviewed. Findings include: On 1/3/2023 at 9:33 am, V7(Registered Nurse-RN) and surveyor went to R76's room. On R76 bedside table were two medications: Trelegy Ellipta inhaler and Ventolin HFA inhaler. V7 said R76 self administers R76 medications and medications stay on R76's bedside table. On 1/3/2022 at 9:40 am, R76 said R76 self-administers the inhalers. R76 said R76 takes Ventolin HFA inhaler four times a day when needed. R76 did not know how long R76 should wait between doses. R76 said R76 takes Trelegy Ellipta inhaler at night. R76 said R76 does not rinse mouth after R76 takes Trelegy Ellipta inhaler. On 1/3/2023 at 11:40 am, V2 (Director of Nursing -DON) said if a resident is to self-administer medications, there should be an order for the resident to self-administer medications. V2 said before a resident is allowed to self-administer medications, an…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-06 · 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

    Based on observation, interview, and record review, the facility failed to change oxygen tubing and failed to properly label oxygen tubing for three residents (R57, R42, R129) reviewed for oxygen therapy in a sample of 28 residents. Findings include: 1. On 01/04/2023 at 11:16 am, R57 observed sitting in a wheelchair located on the 3rd floor dining room of the facility. R57 observed receiving prescribed oxygen therapy via nasal cannula with oxygen tubing connected to an oxygen tank next to R57s' wheelchair. Surveyor observed that R57s' nasal cannula oxygen tubing was not properly labeled with a date and R57s' room number. On 01/04/2023 at 11:18 am, V7 (Registered Nurse/RN) entered the 3rd floor dining room where R57 was located and V7 also observed that R57s' nasal cannula tubing was not properly labeled. V7 stated No, I do not see a date on R57s' oxygen tubing, it should be dated. I'm not sure when R57s' oxygen tubing was last changed. They usually change the oxygen tubing and humidifier on the night shift every Sunday. I can change R57's nasal cannula and date it now. Record review…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

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

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

$4,784 in federal fines across 1 penalty.

  • $4,784 — penalty dated 2025-03-27

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

Part of a chain

This home belongs to LEGACY HEALTHCARE — 89 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 52.9+1.1 vs chain
Health inspection 3 of 52.8+0.2 vs chain
Staffing 2 of 52.5-0.5 vs chain
Quality measures 5 of 53.3+1.7 vs chain
The other 88 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Avantara ArrowheadRapid City, SD 1 of 5Avantara Evergreen ParkEvergreen Park, IL 1 of 5Avantara MilbankMilbank, SD 1 of 5Avantara Saint CloudRapid City, SD 1 of 5Avantara WatertownWatertown, SD 1 of 5Emmetsburg Care CenterEmmetsburg, IA 1 of 5Grove Of Elmhurst, TheElmhurst, IL 1 of 5Harmony Cedar RapidsCedar Rapids, IA 1 of 5Harmony House Health Care CenterWaterloo, IA 1 of 5Harmony MarshalltownMarshalltown, IA 1 of 5Harmony WaterlooWaterloo, IA 1 of 5Harmony West Des MoinesWest Des Moines, IA 1 of 5Nexus at BerwynBerwyn, IL 1 of 5Northgate Care CenterWaukon, IA 1 of 5Park View Rehabilitation CenterSac City, IA 1 of 5Southfield Wellness CommunityWebster City, IA 1 of 5Warren Barr South LoopChicago, IL 2 of 5Avantara GrotonGroton, SD 2 of 5Avantara HuronHuron, SD 2 of 5Avantara Lincoln ParkChicago, IL 2 of 5Avantara Mountain ViewRapid City, SD 2 of 5Avantara Palos HeightsPalos Heights, IL 2 of 5Avantara PierrePierre, SD 2 of 5Avantara RedfieldRedfield, SD 2 of 5Bella Terra BloomingdaleBloomingdale, IL 2 of 5Bella Terra Morton GroveMorton Grove, IL 2 of 5Carlton At The Lake, TheChicago, IL 2 of 5Chalet Living & RehabChicago, IL 2 of 5Colonial Manor of ElmaElma, IA 2 of 5Hallmark Care CenterMount Vernon, IA 2 of 5Harmony DavenportDavenport, IA 2 of 5Harmony DubuqueDubuque, IA 2 of 5Harmony PalosPalos Heights, IL 2 of 5Harmony Utica RidgeDavenport, IA 2 of 5Heritage Care And Rehabilitation CenterMason City, IA 2 of 5Manor House Care CenterSigourney, IA 2 of 5Peterson Park Health Care CtrChicago, IL 3 of 5Avantara LibertyvilleLibertyville, IL 3 of 5Avantara NorthRapid City, SD 3 of 5Bloomfield Care CenterBloomfield, IA

Showing 40 of 88; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleShareSince
DOROS GENERATION TRUST U/A/D 1/3/12Organization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF50%since 05/03/2017
GPN FAMILY TRUST U/A/D 4/28/08Organization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF50%since 05/03/2017
ASTORIA HEALTHCARE PROPERTIES LLCOrganization5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 11/01/2015
VNB NEW YORK LLCOrganization5% OR GREATER SECURITY INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 11/01/2015
SHABAT, MENACHEMIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/03/2017
LEGACY HEALTHCARE FINANCIAL SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/10/2025
SUSS, EZRAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/31/2023
SWIMS, DALEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2015
ROTH & CO, LLPOrganizationADP OF THE SNFsince 01/01/2014

CMS files one row per role, so the 18 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.

6 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.

$15.5M
Net patient revenuemost recent cost report
-15.1%
Operating marginrevenue minus expenses
$3.4M
Related-party expense19% of expenses
Who pays — share of resident-days
Medicaid 24%Medicare 5%Other / private 71%

This home reported $3.4M paid to related parties — landlords or management companies under common ownership — equal to about 19% 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

$332per resident / day
operating cost
$10,081per month
≈ monthly operating cost
$288per day
avg. revenue, all payers

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

What families pay in IL

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.

Typical monthly cost in Illinois
$8,304/mo
Nursing home (semi-private)
$9,216/mo
Nursing home (private)
$6,219/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145634. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-22, 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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