Balmoral Home
2055 West Balmoral Avenue, Chicago, IL 60625 · For profit - Corporation · 213 certified beds · (773) 561-8661 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0600), cited Mar 2026
- it has a citation for mishandling residents’ money or property (F0567)
- it has 2 actual-harm citations
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
- about 30% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 2 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 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 3.3% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.9% | 6.3% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 85.2% | 54.2% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.3% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 4.2% | 14.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 7.4% | 18.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.5% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 11.6% | 20.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 43.3% | 21.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 3.4% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 79.5% | 63.1% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 30.7% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 17.7% | 13.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.37 | 2.02 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.76 | 2.22 | 1.80 | typical |
‡ 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.
Met the expected recovery: 71.9% 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 32 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 0.17 therapist hours per resident per day in 2026Q1 — more than 16% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 45% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.9%CMS range 7.0–13.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 71.9% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 62.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 53.1% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.6% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.1%CMS range 3.9–12.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.91 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 213 beds and averages 178.0 residents a day — about 84% occupied, or roughly 35 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.11 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.39 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.38 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 1.95 hrs/resident/day on weekends vs 2.17 on weekdays — 10% thinner on weekends. RN hours go from 0.43 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
28 citations, most serious first. The 12 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · Gcited before2026-05-22 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to follow standards of practice by not performing a proper nursing assessment of a resident's wound/skin condition, after a certified nursing assistant (C.N.A) notified the nurse of the existence of the wound/skin condition for 1 resident (R5) out of 3 residents reviewed for a skin assessments. This failure resulted in the delay of R5's wound treatment, for a wound that was septic, necrotic, infected with Fournier's gangrene, and required wound debridement.Findings Include:R5's face sheet documents that R5's diagnosis is not limited to peripheral vascular disease, type 2 diabetes mellitus, malignant neoplasm of overlapping sites of bladder, hypertensive heart disease without heart attack, hyperlipemia.R5's MDS (minimum data set) dated 01/01/2026, documents that R5's BIMS (brief interview for mental status) has a score of 14, indicating R5's cognition is intact.R5's hospital records with review date of 02/16/2026 documents in part, R5 presented with symptoms of sepsis, most likely related to skin infection,…
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.
- Actual harm · Gcited before2024-02-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 reviews the facility failed to follow their fall policy to study fall causations, provide corrective actions to prevent reoccurrences, failed to provide adequate supervision and failed to develop specific fall interventions for 1 [R1] of 3 residents reviewed for falls. This failure resulted in R1 sustaining traumatic subarachnoid hemorrhage. Findings Include: R1's clinical record documents in part; R1 is a [AGE] year-old with the medical diagnosis of traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, subsequent encounter, dementia, unspecified severity, with other behavioral disturbance, malignant neoplasm of prostate, secondary malignant neoplasm of bone, muscle weakness (generalized), unsteadiness on feet, abnormalities of gait and mobility, cognitive communication deficit, acute kidney failure, altered mental status, mild neurocognitive disorder due to known physiological condition with behavioral disturbance, anemia, protein-calorie…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-28 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure physician's orders were followed for one resident (R1). This failures affected one of three residents reviewed for medication administration. Findings include: R1's Brief Interview for Mental Status (BIMS) dated 6/12/26 does not show a score of however during this interview R1 was able to answer surveyor's questions. R1 has a diagnosis which includes but not limited to chronic obstructive pulmonary disease, low back pain, essential hypertension, anxiety disorder, bipolar, primary insomnia, epilepsy, and hypoparathyroidism. R1's Physician Order Sheet (POS) dated 6/19/26 documents, in part: Nicotine Polacrilex Mouth/Throat gum 4 mg (Nicotine Polacrilex) give 1 gum by mouth every 2 hours as needed for smoking cessation. On 6/26/26 at 11:48 am, V7 (Licensed Practical Nurse, LPN) stated that R1 has orders to receive nicotine gum 1 piece of gum every 2 hours. V7 then explained that when she is assigned as R1's nurse, she will give 4 pieces of nicotine gum at time because R1 will constantly come to V7 every…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-22 · tag F0567 — failed to protect residents' money held by the home — isolatedHonor the resident's right to manage his or her financial affairs.
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 staff interviews and record review, the facility failed to protect the right of the resident to access their personal funds without restriction by placing a resident on a money management program as a form of behavioral punishment. This failure affected 1 resident (R4) out of 4 residents reviewed for resident funds. Findings included:R4's Face Sheet documents resident is an [AGE] year-old with diagnoses including but not limited to: Hypertensive heart disease without heart failure, adult failure to thrive, pain in right hip, anemia, neuralgia and neuritis, retention of urine, nicotine dependance, cigarette non-compliance. Minimum Data Set Section (MDS) section C (dated 05/05/2025) documents that R4 has an Interview for Mental Status (BIMS) score of 15, indicating that R4's cognition is intact. R4's Care plan (dated 02/05/2024) states: SMOKING MANAGEMENT/NON-COMPLIANCE: Resident was reported using smoking materials in an inappropriate/risky manner (setting pieces of paper on fire in his room). Smoking…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-22 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents were free of abuse/physical assault. This failure affected three residents (R3, R4, and R5) of five residents reviewed for resident-to-resident abuse in the facility.Findings include: R1's medical diagnoses include but are not limited to right heart failure, schizoaffective disorder, essential hypertension, type 2 diabetes. R1's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 14, indicating R1's cognition is intact. R1's progress note dated 02/27/26 at 1:40pm documents in part, SSD (Social Service Director) made aware resident physically attacked peer unprovoked. R1's progress note dated 02/27/27 at 3:20pm documents in part, Resident was observed with physical/aggressive behavior to co resident by hitting and pushing him out of his wheelchair. R4's medical diagnoses include but are not limited to quadriplegia, schizophrenia, and traumatic brain injury. R4's MDS dated [DATE] has a BIMS…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to supervise and prevent a resident who repeatedly stated she did not want to be in the facility from eloping from the facility. This failure affects one (R6) out of three residents reviewed for supervision in a total sample of three residents. Findings include: R6's MDS/Minimum Data Set, dated [DATE] documents that R6 has a BIMS/Brief Interview for Mental Status of 15/15, indicating that R6 is cognitively intact without any memory problems. R6's MDS documents that R6 ambulates via walking without any impairment and without assistive devices. R6 requires supervision with ADL/Activities of Daily Living care and mobility. R6 is continent of bowel and bladder. R6's progress notes are as follows: 02/24/2026 at 3:54PM written by V4 (ADON/RN) Received [AGE] year-old resident from hospital with admitting diagnosis of schizophrenia. R6 is AxOX3. Ambulatory without any assistive device. Orders verified with both MD. R6 on general diet, thin liquids. Upon…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ddisputed · IDR2025-11-26 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably 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 observations, interviews and record reviews, the facility failed to provide wheelchairs to residents that were in safe and working condition to 3 (R12, R13 and R14) of 3 residents reviewed for concerns on properly functioning wheelchairs. This failure had the potential to result in accidents and safety hazards. Findings Include:R12's Face Sheet documents that R12 was admitted to the facility on [DATE] with a diagnosis of nontraumatic intracerebral hemorrhage, traumatic subdural hemorrhage epileptic seizures related to external causes, chronic kidney disease, and hypertensive heart disease without heart failure aneurysm of the descending thoracic aorta.R12's last quarterly Minimum Data Sheet (MDS) documents a Brief Interview for Mental Status (BIMS) score of 14 indicating cognitively intact with little to no impairment. R12's MDS dated [DATE] shows impairments to both R12's upper and lower extremities and requires substantial to maximum assistance in all activities of daily living (ADL) categories except…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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 review of records, interviews and observations facility failed to follow preventive measures to address sacral pressure ulcer care for 1(R2) out of 3 residents for a total of 3 residents reviewed for skin care. This failure resulted to one resident (R2) sustaining pressure ulcer deterioration. Findings include: R2 is [AGE] years old, initially admitted on [DATE]. R2's medical diagnosis includes Parkinson's disease and muscle weakness. R2 was seen on 04/08/2025 at 12:30 PM, in his room alert and verbally able to response within topic during conversation. R2 replied when asked if he has wounds, Yes, I have on my back. R2 stated that dressing was not change yesterday and today. But was changed a couple of weeks ago. R2 was seen laying on his back. When asked if staff are turning him (R2) on his side? R2 replied, No, they don't turn me on my side. They turn me when they change my dressing on my back. But not daily. R2's feet seen pushing on the footrest without heel protector. Per V6 (Nurse Practitioner…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-11 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review or records and interview the facility failed to provide accurate treatment administration record for 1(R2) out of 5 residents for a total of 5 residents reviewed. This failure resulted to inaccurately representing one (1) resident (R2) treatment of pressure ulcer care in the facility. Findings include: R2 is [AGE] years old, initially admitted in the facility on 03/01/2010. R2 medical diagnosis includes Parkinson's disease, bipolar disorder and muscle weakness. On 04/08/2025 at 12:30 PM, R2 was seen in his room alert and verbally able to response within topic during conversation. R2 replied when asked if he has wounds, Yes, I have on my back. R2 stated that dressing was not change yesterday and today. But was changed a couple of weeks ago. R2 was seen laying on his back. When asked if staff are turning him (R2) on his side? R2 replied, No, they don't turn me on my side. They turn me when they change my dressing on my back. But not daily. R2's feet seen pushing on the footrest without heel…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to supervise and monitor a cognitively impaired resident with known behaviors of ingesting non-edible, toxic items from obtaining those items. This failure affects one of three residents (R2) reviewed for supervision in a total sample of three residents. Findings include: 03/08/2025, 9:53 AM, R2 was sitting on a chair next to her bed. R2's overbed table was next to her with her personal items within reach. A 4 oz (ounce) baby powder bottle and liquid soap in a clear cup on were her overbed table. 03/08/2025, 11:03 AM, with V2 (Assistant Administrator) present, R2's overbed table observed with baby powder. V5 (Certified Nursing Assistant) entered the room. R2 was questioned who gave you the powder. R2 pointed to V5 and stated that young lady. R2 states that she got the liquid soap from someone at the nurse's station but cannot recall who. 03/08/2025, 10:51 AM, via telephone, V6 (Certified Nursing Assistant) states that she has worked for the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-12-04 · tag F0554 — patternAllow 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 assess a resident for safe self-administration of medications. This failure affected one resident (R148) and has the potential to affect all 56-residents residing on the second floor. Findings Include: The (12/03/2024 email correspondence with V10 (Assistant Administrator documented that there were 56 residents on the second floor. R148's admission diagnoses include but not limited to dermatitis, atrial fibrillation, congestive heart failure, and dementia. R148's Brief Interview of Mental Status (BIMS) score is 11 which indicates R148 has moderate cognitive impairment. On 12/1/24 at 10:30 am, observation of Zinc oxide 20% ointment in a long white tube on R148's nightstand. On 12/2/24 at 1:10 pm observation of Zinc oxide 20% ointment and triamcinolone acetonide 0.5% ointment in long white tubes on R148's nightstand. On 12/3/24 at 12:25 pm, observation of triamcinolone acetonide 0.5% ointment on R148's nightstand in a container with toothpaste. On 12/3/24 at 12:30 pm, surveyor inquired to V14 RN (Registered…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-12-04 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure that medications were signed out when administered for four residents (R8, R43, R81, and R97). This failure affected four residents in the sample of 57 residents. Findings include: On 12/02/24 at 8:58 am, Surveyor requested to observe medication pass on the first floor Team 2 cart with V18 (Licensed Practical Nurse, LPN) and V18 stated that V18 completed the 9:00 am medication pass. Surveyor and V18 reviewed R8, R43, R81, and R97's Medication Administration Record (MAR) and observed R8, R43, R81 and R97's medications not signed out for the 9:00 am medication pass. V18 stated, I (V18) gave them, but I (V18) did not get a chance to sign them out. I (V18) was going to sign them in a few minutes. R8's MAR presented by the facility on 12/02/24 shows the following medications for R8's were not signed after being administered by V18 for the 9:00 am medication pass on 12/02/24: Anastrozole 1 mg tablet by mouth Aspirin Enteric Coated (EC) 81 mg tablet by mouth Daily Vite tablet by mouth Docusate Sodium 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.
Show the remaining 16 citations
- Potential for harm · Ecited before2024-12-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure that a resident (R120) smoke at a designated smoking area; and failed to ensure that environment was free from hazards (razors) for three residents (R36, R116 and R148). These failures have the potential to affect all 47 residents on the first floor, and all 56 residents on the second floor at the facility. Findings include: The (12/03/2024 email correspondence with V10 (Assistant Administrator documented that there were 47 residents on the first floor. On 12/01/24 at 10:40 am, Surveyor observed R116 in R116's room holding 3 shaving razors in R116's right hand. R116 stated that R116 was given the 3 razors from staff 3 days ago to shave R116's head. R116 stated that R116 receives razors from staff to shave R116's head and face. When R116 was asked regarding where does R116 store the razors in R116's hand R116 stated in R116's room. On 12/01/24 at 11:29 am, V12 (Licensed Practical Nurse, LPN) was asked regarding residents with razors and V12 stated that residents cannot have razors due to safety. V12…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-12-04 · tag F0755 — failed to provide safe pharmacy services — patternProvide 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 follow policy of reconciling controlled substances at the end of each shift. This failure has a potential to affect all 4 residents receiving controlled substances on the 1st floor. Findings include: Facility presented list of residents taking controlled medications on first floor which totaled 4 residents. On 12/1/24 at 11:40 am, during facility rounds with V12 Agency Licensed Practical Nurse(LPN) document called Controlled Substance Check Form did not have signatures of a narcotic shift to shift count for 12/1/2024. V12 stated she did not count narcotics with the night nurse at the start of her shift. 12/03/24 at 01:40 PM The Director Of Nursing (DON) V2 stated that the Nurses need to count narcotic medications between incoming and outgoing nurses at the end of each shift. V2 also stated if the nurses did not do the narcotic shift to shift count they will all be in trouble and they will have to investigate any discrepancies. Facility presented an undated policy titled Controlled Substances which documents:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-12-04 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 ensure medications were stored at proper temperatures in two of three medication refrigerators reviewed for medication storage; failed to secure Schedule II controlled drugs and other controlled drugs subject to abuse in a separately locked compartment separate from non- controlled drugs; and failed to ensure medications including controlled drugs of two of two residents (R159 and R262) that expired are disposed timely. These failures have the potential to affect 47 residents residing on first floor and 56 residents residing on third floor of the facility. Findings include: The ([DATE] email correspondence with V10 (Assistant Administrator documented that there were 47 residents on the first floor and 56 residents on the 3rd floor. On 12-1-2024, at 11:10 AM, during rounds with V12, Licensed Practical Nurse (LPN) on the 1st floor medication refrigerator was noted with frost in freezer area of the refrigerator and temperature was 42 degrees…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-04 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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 refer one resident (R126) for rescreening to the state agency for Preadmission Screening and Resident Review (PASRR). This deficient practice affected one resident (R126) in a total sample size of 57 residents. Findings include: R126's admission date to the facility is 10/11/24. R126's PASRR (Preadmission Screening and Resident Review) level 1 outcome dated 08/29/24 documents in part, No level II required - No SMI (serious mental illness). R126's diagnoses on 10/11/24 include but are not limited to bipolar disorder current episode manic without psychotic features, schizophrenia, essential hypertension. R126's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score 14 which indicates R126's cognition is intact. On 12/03/24 at 11:19am V10 (Assistant Administrator/AA) stated that level 2 PASRR's are done when the resident has a mental diagnosis. V10 stated that a diagnosis of schizophrenia and bipolar should be included on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-04 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 label and date oxygen equipment (oxygen tubing and nebulizer mask per the facility's policy. These failures affected two residents (R54 and R126) reviewed for oxygen equipment, in a total sample of 57 residents. Findings include: R54's diagnoses include but are not limited to heart failure, type 2 diabetes mellitus without complications, chronic kidney disease stage 3, essential hypertension, atrial fibrillation, acute respiratory failure, anxiety disorder, chronic obstructive pulmonary disease, morbid obesity. R54's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 8 which indicates R54's cognition is moderately impaired. R54's physician order dated 05/10/24 documents in part, change oxygen tubing and humidifier weekly or as needed. R54's care plan dated 03/04/23 documents in part, CHF: the resident has congestive heart failure .Give oxygen as ordered by the physician. R126's diagnoses include but…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-04 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure that medication that fell on the floor was not administered to a resident (R55). This failure affected one resident (R55) in the sample of 57 residents. Findings include: On 12/01/24 at 12:34 pm, Surveyor observed V12 (Licensed Practical Nurse, LPN) administer medication to R55 during the first floor noon medication pass. Surveyor observed V12 drop R55's Divalproex Sodium DR (Delayed Release) 500 mg (Milligram)1 tablet on the floor next to R55's wheelchair, then pick up R55's Divalproex Sodium DR (Delayed Release) 500 mg (Milligram)1 tablet from the floor next to R55's wheelchair and then administer R55's Divalproex Sodium DR (Delayed Release) 500 mg (Milligram)1 tablet to R55 orally. On 12/01/23 at 12:52 pm, Surveyor asked V12 regarding administering medications that have falling on the floor to a resident and V12 stated that if a medication falls on the floor the nurse should discard the medication and give the resident another pill. When V12 was asked regarding the importance of discarding…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-04 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide a comfortable environment to one resident (R162). This failure affected one resident in a total sample size of 57 residents. Findings include: On 12/01/24 at 10:58am, surveyor entered R162's room and felt cold from a decrease in temperature. On 12/01/24 at 11:00am, R162 stated that he that he had been complaining of the cold temperature in his room since Wednesday 11/27/24. On 12/01/24 at 11:11am, V13 (Licensed Practical Nurse/LPN) stated that R162's room is as cold as the weather outside. V13 stated that a room that is too cold is an immediate need. On 12/01/24 at 11:56am, V5 (Maintenance Director) stated that no one had informed him that R162's room was cold. V5 checked R126 room with hand thermometer. Hand thermometer showed temperature 61 degrees Fahrenheit. V5 stated that R126's room temperature should be at least 68 degrees Fahrenheit. V5 stated that R126's room is cold due to a crack in the window. On 12/02/24 at 09:11am, V5…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-01-12 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and records review, the facility failed to properly label, store and discard expired medications in a medication cart that serves 21 residents on the second floor. This deficiency has the potential to affect R12, R18, R76, R37, and 21 residents receiving medications from the second floor, team two medication cart, in a sample of 30 residents reviewed. Findings include: On 01/09/2024 at 9:46am, during review of medication cart on the second-floor team two, with V11 (Registered Nurse-RN), surveyor and V11 observed following expired medications on the cart as follows: R37 Latanoprost 0.005 % eye drops -No opened or expiration date on the medication. R12 Lantus 100 units /ml (milliliter) insulin vial - Opened date 11/29/2023. Expiration date noted on the medication bottle-12/27/2023 Humalog 100 units/ml insulin vial - Opened date 11/27/2023. Expiration date: 12/27/2023. R18 Humalog 100 units/ml insulin vial - Opened vial, no date when opened or when medication will expire. R76…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-11 · tag F0697 — failed to manage pain — isolatedProvide 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 review of records and interviews the facility failed to follow pain management policy related to documentation of pain, assessment of pain, and following physician order in giving pain medication for 1 out of 4 residents (R2) reviewed for pain management. Findings include: R2 was [AGE] years old, with diagnosis of intervertebral disc disorders with radiculopathy, lumbar region, arthritis, low back pain. R2 was initially admitted on [DATE]. Per resident record on 10/14/2023 at 2:07 PM, R2 was discharged against medical advice. R2's handwritten notes read as follows: due to arthritis, back and neck pain, laminectomy surgery (10/3/2023) leg pain management. R2 has incision on her lower back. To give Hydrocodone - Acetaminophen (Norco) 10 - 325 MG (milligrams)every 4 hours or round the clock. On 12/19/2023 per V3 (Director of Nursing) this document is used by nurses during admission getting instructions from the hospital. Before arriving in the facility, hospital record monitoring pain of R2 dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-10 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Failures resulted in two deficient practice statements. A. Based on observation, interview, and record review, the facility failed to follow their Aspiration Precautions policy and follow speech therapy recommendations for 2 (R12 and R66) of 29 residents reviewed for improper nursing care. B. Based on observation, interview, and record review, the facility failed to follow policy and procedure on glucometer cleaning to prevent cross contamination for 2 (R110, R143) of 3 residents observed for blood glucose monitoring during medication administration. The facility also failed to follow its Enhanced Barrier Precautions policy for one resident (R122) by not sanitizing hands prior to and after entering resident's room. Findings include: A.1. R66's diagnoses include but not limited to abnormal posture, gastro-esophageal reflux disease, and dysphagia. R66's Physician Orders include orders for STRICT ASPIRATION PRECAUTIONS and FEED SLOW, NO STRAWS. R66's Nutritional Risk Review assessment dated [DATE] documents in part…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-10 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 low air loss mattress devices were properly working and on the correct setting for 2 (R11, R146) of 2 residents identified as at risk for developing pressure ulcers in a sample of 29 residents reviewed for skin preventative measures. Findings include: 1. On 3/07/23 at 2:15 PM, R146 was lying in bed alert but confused. R146's low air loss mattress was deflated, and the device was unplugged. At 2:17 PM, surveyor entered R146's room with V31 (Registered Nurse) and stated R146 had pressure ulcers on R146's sacrum that were healed and should have the low air loss mattress for preventative measures. V31 stated that the low air loss mattress machine should be on when R146 is in bed. At 2:20 PM, during interview V31 stated that bedridden residents who are at risk for developing pressure ulcers should have the low air loss mattress to prevent them from developing pressure ulcers. V31 stated that the correct setting should be based on the resident's weight and should be turned on when the resident is in bed. V31…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-10 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure adaptive devices were applied to residents' hands to prevent further contracture or deformities. This failure applies to 2 (R22, R35) residents out of 4 residents reviewed for limited range of motion in the final sample of 29 residents. Findings include: 1. On 3/7/23 10:59 AM R22 was observed lying on bed, head of bed elevated. R22 was observed with bed on lowest position and floor pads. R22 was observed alert but non-verbal, able to nod head. Surveyor observed R22's left hand contracted, fist closed with no adaptive device or splint. At 12:06 pm R22 was observed lying on bed, left hand fist closed with no adaptive device. Observed staff assisting R22 at lunchtime. On 3/8/23 at 12:18pm V23 (Restorative Nurse/Registered Nurse/RN) was interviewed and stated that she has been working in the facility for 2 years. V23 stated that residents are assessed for adaptive or assistive device upon admission, readmission, quarterly and significant changes. R22's electronic health record was reviewed with V23 and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow smoking safety policy to provide a safe and healthy living environment with respect for the health and well-being needs of each resident, staff member and visitor. This failure applies to 1 (R85) resident who is on supervised smoking out of 5 residents reviewed for smoking in the final sample of 29 residents. Findings include: On 3/7/23 11:38 AM R85 was observed sitting in a high back wheelchair by his bedside tray table in his room. Surveyor observed a pack of cigarettes on the bedside tray table. R85 is alert and verbally responsive. R85 stated he is a smoker, and he keeps his own cigarettes and lighter. Survey team observed R85 in the 1st floor dining room in a wheelchair holding a pack of cigarettes in his right hand. On 3/8/23 at 12:05pm V22 (Social Service Director) was interviewed and stated that she has been working in the facility for 15 years. V22 stated that smoking assessment is being done upon admission and annually or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-10 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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 food trays were distributed in a sanitary manner to prevent contamination for 1 (R130) resident being served food on the first floor in a sample of 29. Findings Include: On 03/07/23 at 11:27 AM dietary staff were observed on the first floor with the steam table in hallway in front of the men's shower room serving food trays. On 03/07/23 at 11:34 AM V11 (Activity Aide) placed a used plate cover on the overbed table next to two pitchers of red juice. On 03/07/23 at 11:36 AM V9 (Agency Certified Nurse Assistant) removed the used plate cover that was placed on the overbed table by V11 (Activity Aide), placed the plate cover over R130's food then proceeded down the hallway and delivered the food tray to R130's room. V9 returned to the steam table. Surveyor asked V9 did she (V9) realize that the plate cover that she (V9) used to cover R130's plate was already used to cover and deliver a food tray to another resident. V9 stated, No I did not realize that the plate cover had already been used. There is a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2024-12-04 · tag F0732 — widespreadPost nurse staffing information every day.
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 Daily Nursing Staffing was posted daily and failed to ensure the Daily Nursing Staffing was completed appropriately. These failures have the potential to affect all 159 residents residing at the facility. Findings include: The (12/01/2024) Facility daily census was 159. On 12/01/2024 at 12:00pm by the reception area with V9 (Scheduler). This surveyor requested V9 to provide the Daily Staffing Posting for 12/01/2024. V9 looked around the reception area and stated it is not here. V9 inquired if this surveyor was looking for the Daily Staffing Schedule. This surveyor requested to see the Daily Staffing Schedule. On 12/01/24 at 12:05 PM by the first-floor nurse's station, V9 pulled a document from a clipboard and showed this surveyor the Daily Staffing Schedule for 12/01/2024. The form did not indicate the current number of residents and there were no hours for Registered Nurses, Licensed Practice Nurses and CNAs for each shift. This surveyor inquired for the total number of hours for registered nurse,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2023-03-10 · tag F0656 — failed to write and follow a full care plan — widespreadDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives or goals and interventions to meet the residents' needs for 6 (R90, R103, R52, R22, R85, R134) residents reviewed for advance directives. This has the potential to affect all 142 residents per the census on [DATE]. Findings include: On [DATE] at 2:38 PM R90's health record reviewed and documented that R90's admission date was on [DATE] with diagnoses not limited to asthma, schizophrenia, post-traumatic stress disorder, and bipolar disorder. R90's Physician Order Sheet (POS) for 3/2023 documented in part: Advance Directive - FULL CODE. R90's Practitioner Order Life-Sustaining Treatment (POLST) form completed on [DATE] documented in part: Attempt resuscitation/CPR, Full Treatment. No existing care plan was found both on paper or in the electronic health record At 2:17 PM R103's POS for 3/2023 documented in part: Advance Directive - FULL CODE. POLST form…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| JOSEPH A MERMELSTEIN TRUST DTD 7/15/99 | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; TRUSTEE OF THE SNF | 50% | since 06/18/2018 |
| MARVIN MERMELSTEIN FAMILY TRUST | Organization | INDIRECT OWNERSHIP INTEREST | — | since 06/18/2018 |
| STERN, YONATHAN | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/18/2018 |
| KLEIN, TOM | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2019 |
| MERMELSTEIN INVESTMENT PARTNERS LP | Organization | ADP OF THE SNF | — | since 07/01/2021 |
CMS files one row per role, so the 9 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $4.1M paid to related parties — landlords or management companies under common ownership — equal to about 30% 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.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145796. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-12-04, 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.