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Birchwood Plaza

1426 West Birchwood, Chicago, IL 60626 · For profit - Corporation · 200 certified beds · (773) 274-4405 Medicare & Medicaid certified

Call the home — (773) 274-4405 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (26% vs 45% nationally) — better care continuity
Worth asking about
  • it has 1 actual-harm citation
  • 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

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

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

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

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1506 W Howard St · (773) 465-0695 · Call to confirm hours
Pharmacy
7410 N Clark St · (773) 743-6784 · Call to confirm hours
Grocery
1506 W Jarvis Ave · (773) 761-3663 · Call to confirm hours
Park
7615 N Bosworth Ave · (773) 850-0049 · Typically dawn to dusk
Place of worship
7450 N Sheridan Rd · (773) 274-7441

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 3 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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

Trend — is this home getting better or worse?

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

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased15.7%13.4%15.4%typical
Long-stay residents who lose too much weight3.3%6.3%5.4%better
Long-stay residents with a catheter left in their bladder1.9%0.9%0.9%worse
Long-stay residents with a urinary tract infection4.2%1.5%2.0%worse
Long-stay residents with depressive symptoms100.0%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 injury2.1%3.1%3.3%better
Long-stay residents whose ability to walk worsened11.2%14.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication6.0%18.3%18.9%better
Long-stay residents given the seasonal flu vaccine98.0%91.8%95.3%typical
Long-stay residents with pressure ulcers5.0%4.8%4.7%typical
Long-stay residents with worsening bladder/bowel control21.1%20.6%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table17.2%21.7%17.1%typical
Short-stay residents who newly got an antipsychotic medication4.1%2.2%1.4%worse
Short-stay residents given the seasonal flu vaccine59.5%63.1%79.4%worse
Short-stay residents rehospitalized after admission19.2%26.1%22.6%better
Short-stay residents with an outpatient ER visit12.6%13.9%12.0%typical
Long-stay hospitalizations per 1,000 resident days2.782.021.67worse
Long-stay outpatient ER visits per 1,000 resident days1.192.221.80better

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.

42.1% 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 66 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

42.1%U.S. median 51.5%
Got home and stayed home
10.4%U.S. median 10.7%
Went back to hospital
75.4%U.S. median 56.6%
Met the expected recovery
0.17U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 75.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 61 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 20% 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 SNF42.1%CMS range 29.9–54.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 6.8–14.510.7%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 discharge75.4%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge77.0%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 discharge55.7%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 identified98.8%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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.5%CMS range 4.9–14.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.991.02Oct 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

0.75
RN hours/ resident / day
0.23
LPN hours/ resident / day
2.13
Aide hours/ resident / day
3.11
Total nurse hours/ resident / day
0.62
RN hoursweekends
25.7%
Total nursing turnover
5.3%
RN turnover

How full it usually is: this home is certified for 200 beds and averages 138.4 residents a day — about 69% occupied, or roughly 62 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.11 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.75 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.13 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 3.17 on weekdays — 6% thinner on weekends. RN hours go from 0.81 to 0.62 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 26% is below the national median of 45%.

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

Inspection trend

8
deficiencies at the latest standard inspection (2025-04-03)
8
at the previous standard inspection (2024-03-08)

Deficiencies are unchanged from the previous inspection. 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.

28 citations, most serious first. The 11 most serious are shown; the remaining 17 are one tap away and print in full.

  • Actual harm · Gcited before2023-09-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to properly transfer a resident (R2) who is totally dependent on staff for transfers; and failed to ensure that R2 was free from injuries of unknown origin for one of four residents (R2) reviewed for Injury of Unknown Origin on the sample list of four. These failures resulted in R2 sustaining a left tibia comminuted fracture involving the tibia with multiple fracture clefts, pain and swelling to the left leg. Finding include: R2's face sheet shows that R2 has a diagnosis which includes but not limited to: Nondisplaced comminuted fracture of shaft of the left tibia subsequent encounter for closed fracture with routine healing. R2's Minimum Data Set, dated [DATE] shows that R2 requires Total dependence two-person assistance for transfers. R2's Brief Interview for Mental Status (BIMS) shows that R2 has memory problems. On 09/25/23 at 12:23 PM, R2 was observed in bed awake and alert not able to communicate needs. V4 (Certified Nursing Assistant) was observed…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-04-03 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that staff are feeding residents from a seated position during dining service which affected R7, R62, R73, and R77 in the total sample of 75 when reviewed for resident rights. Findings include: On 3/31/25 at 11:41 am, V13 (Certified Nursing Assistant, CNA) observed positioning R77 upright in R77's reclining wheelchair and provided R77 the lunch meal tray on top of the table over R77's lap. V13 opened up R77's plate cover to reveal a puree diet, set up food items close to R77 and utensils within reach. R77 began slowly touching a bowl on R77's tray. On 3/31/25 at 11:47 am, R77 is observed trying to eat the puree diet meal tray in front of R77 without R77 actively spooning food into R77's mouth. On 3/31/25 at 11:53 a.m., V13 (CNA) was observed standing next to R77, looking down at R77 in the reclining wheelchair. While in a standing position, V13 took R77's utensil and fed R77 three bites of food from R77's lunch meal tray. V13 then…

    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 before2025-04-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide fall prevention interventions for residents who are at risk for falls and failed to ensure that residents at risk for falls do not have repeated falls. These failures affected 3 residents (R23, R43, and R58) who had repeated falls, and have the potential to affect one resident (R34), reviewed for falls and fall prevention interventions, in a total sample of 75 residents. Findings include: On 4/2/25 R23 was observed sitting at the edge of the bed with no staff nearby in the hallway. R23 had a wound dressing on the right foot and dark blue sock with smooth bottom on the left foot. The surveyor asked R23 if he(R23) needed some help. R23 stated that he's trying to exercise his legs. The surveyor called V23(RN/Registered Nurse) to assist R23. V23 stated I will get the CNA (Certified Nurse Assistant) to give him non-skid socks. Inquired from V23 if it was okay for R23 to not have proper footwear while awake and trying to exercise at the bedside, considering the fact that R23 has had several falls in the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-03 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 records review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program and failed to refer level II residents and residents with possible serious mental disorder and/or intellectual/developmental disability, for level II resident review upon a significant change in a mental status assessment. These failures affected three residents (R22, R34, R76) and have the potential to affect additional 34 residents with diagnosis of mental disorder and/or intellectual/developmental disability in the whole facility in a sample of 75. Findings include: On 3/31/2025 at 2PM, Review of facility's admission Record, shows R22 admission Date to facility on 3/27/2012, with diagnosis included but not limited to: Unspecified Dementia (Unspecified Severity), Major Depressive Disorder (Recurrent), bipolar disorder (Unspecified), Hemiplegia and Hemiparesis following nontraumatic intracerebral Hemorrhage. On 04/01/25 at 12:55 PM, facility…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-03 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 a resident's psych diagnoses were included in the pre-admission screening. This failure affected 1 (R109) resident reviewed for accuracy of pre-admission screening in the total sample of 75 residents. Findings include: R109's (printed 03/31/2025) Diagnosis Report documented that R109's diagnoses: (include but not limited to) schizoaffective disorder and schizophrenia with onset date of 05/24/2022. R109's (5/24/2022) Psychotropic consent documented, in part Risperdal 0.5mg twice daily. Supporting Diagnosis: Schizophrenia. R109's (Active Order as Of: 04/03/2025) Order Summary Report documented, in part Anti-psychotic episodic medication Use: monitor and observe. Active: 02/25/2023. Behavior monitoring related to psychotic disorder with delusions due to known physiological condition, schizophrenia, schizoaffective disorder. RISPERIDONE 0.5 MG TABLET Give 1 tablet orally two times a day related to SCHIZOPHRENIA. Active. 02/25/2023. R109's (Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-03 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide timely oral care for a dependent resident (R44) and failed to provide personal hygiene shaving care for a female, dependent resident (R56) which affected 2 residents (R44, R56) in the total sample of 75 residents when reviewed for activities of daily living (ADL) care. Findings include: On 3/31/25 at 11:14 am, R56 is observed laying in bed and noted with mustache hair that is dark gray hair on upper sides of lips. R56 is observed with gray and white hair chin hair, about 1/2-3/4 inch in length, on underside of R56's chin. When asked if R56 is comfortable with the lengthy facial hair, R56 stated, I (R56) would prefer not to have it. When asked if R56 has been offered during ADL care by the CNA to shave the facial hair, R56 stated no. R56 stated, I would take care of it at home, but I am not at home and need help. R56's admission Record documents, in part, diagnoses of chronic obstructive pulmonary disease, chronic respiratory…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-03 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident ordered for Enteral g-tube (gastrostomy tube) feeding received the correct amount of Enteral feeding. This failure affected one resident (R76) out of one resident reviewed for Enteral/G-tube feeding in a sample of 75 residents. Findings include: On 3/31/25 at 10:35 AM, R76 was observed laying in her bed resting. R76 is alert and talkative, denies pain or discomfort when asked on interview. R76's Enteral g-tube feeding bottle was observed with a date of 3/31/25 but the Enteral g-tube feeding machine was off and not connected to the resident at that time. R76's Enteral g-tube bottle was observed by this surveyor with 1/3 of the Enteral g-tube feeding amount gone from the bottle. On 3/31/25 at 10:40 AM, V12(Licensed Practical Nurse, LPN) stated she did not turn the g-tube feeding off and doesn't know who turned it off or how long it was off. On 04/01/25 at 11:00 AM, V12(LPN) stated she is the nurse in charge of R76 and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-03 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that staff perform hand hygiene during resident dining service prior to feeding a resident, in between feeding separate residents, and after staff touching their personal body then feeding a resident to prevent and/or contain the possible spread of infectious microorganisms. These failures affected R28, R43 and R77 in the total sample of 75 when reviewed for infection control. Findings include: On 3/31/25 at 12:00 pm, V13 (Certified Nursing Assistant, CNA) observed sitting on the stool chair feeding R77 in the dining room. V13 is observed sitting positioned next to R77 (who is sitting on V13's right side) and also next to R43 (who is sitting on V13's left side). R43 is observed feeding R43's self while sitting in R43's reclining wheelchair. V13 observed stopping from feeding R77, and V13 reaches over to R43's tray then touches and moves R43's blue coffee cup which was in contact with the remainder of R43's brown bread crusts that…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-12-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to ensure that medication cart, treatment cart with residents' medication was not left un-attended and unlocked when not in the visual proximity of the nurse and not in use to prevent tampering and accidental hazard. This failure has the potential to affect all the 40 residents residing on the 1st floor of the facility. Findings include: On 12/24/24, at 10:30 AM, on the 1st floor, the medication cart was noted in the hallway without a nurse present and not within the nurse vicinity. V6 LPN (Licensed Practical Nurse) who oversaw the medication cart stated that I just went to pick up something. When asked about facility policy on medication storage /medication cart storage. V6 stated that the medication cart must be locked when not in use or where the nurse can see it. At 10:40 AM, the treatment cart was noted unattended to and unlocked with resident treatment medication noted in the cart in the hallway. When V2 DON (Director of Nurse's) who was coming out of the elevator was shown the cart and was asked about 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 · Ecited before2024-12-26 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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 prevent co-mingling of dented food cans with undented ones; failed to ensure that the ice machine is in a clean condition and failed to label, discard left-over food items, and prepared food items according to their food labeling policy and procedure. This failure has the potential to affect all 145-residents eating from the facility kitchen. Findings include: On 12/24/24, at 10:10 AM, during kitchen observation with V1 (Administrator) and V5 (Dietary Manager) the following were observed: In the dry storage room [ROOM NUMBER] LBS banana pudding can and 6.5 LBS diced peaches were observed dented and co-mingled with un-dented cans. V5 stated that I don't usually put them together (stored) but it a is a small dent and it's nothing. V1 who was present at the time stated, they should be removed. In the 2nd dry storage area, a white bucket labelled breadcrumbs noted with no open date and no used by date. In the walk-in freezer, seven (7)…

    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 before2024-03-08 · 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 observations, interviews, and record reviews, the facility failed to ensure food items were labeled, discard expired food items, label dry storage items with a delivery date to ensure first-in-first-out policy is followed and store scoops outside of food bins. These failures have the potential to affect all 142 residents receiving food prepared in the facility's kitchen. Findings include: On 03/05/24 at 9:32 AM, started initial kitchen tour with V4 (Dietary Aide) because V5 (Food Service Supervisor) was not in the building yet. V4 stated everything in the walk-in refrigerator should be labeled and dated with a prepared date and use by date. V4 stated prepared food items should be discarded after seven days. On 03/05/24 at 9:50 AM, V5 (Food Service Supervisor) arrived in the kitchen and stated all items in the refrigerator need to be labeled and dated so that the staff knows when to discard what has been prepared. Items need to be used within seven days with day one being the date the food was prepared. On 03/05/24 between 9:36 AM - 10:12 AM, observed the following items 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · F2024-03-08 · 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 dumpster was covered to prevent the harborage and feeding of pests, insects, and rodents. This deficient sanitation practice has the potential to affect all 144 residents who reside in the facility. Findings include: On 03/05/24 at 11:05 AM, during observation of the outside garbage dumpster with V5 (Food Service Supervisor) observed large dumpster with 2 of the 6 lids wide open with garbage bags bulging out of the opened lids. V5 stated the lids should always be closed to prevent garbage from blowing out and to prevent rodents from getting inside. V5 stated this is important because we don't want rodents near the building. V5 trying to close the lid of the dumpster but it would not fully close all the way because the dumpster was too full of garbage. On 03/06/24 at approximately 9:30 AM, three surveyors observed a dead rodent in the facility driveway close to the side of the building by the side entrance. On 03/06/24 at 12:58 PM, V14 (Housekeeping/Laundry Supervisor) stated V14 tells the housekeeping…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-08 · 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 ensure a resident was treated with respect and dignity by not passing out meals to residents sitting together at the same time affecting 1 (R134) of a total sample of 31 residents reviewed for dining services. Findings include: On 03/06/24 at 11:53 AM, surveyors arrived on the 3rd floor dining room with meal service already in progress. Observed R134 sitting at a table with R6, R71, R102. R6, R71, R102 had meal trays in front of them and were all actively eating. R134 did not have a tray. R134 did not have any food or drink in front of him. Observed R134 watching R6, R71 and R102 eating their lunch. On 03/06/24 at 11:56 AM, R134 stated R134 is waiting for R134's tray. On 03/06/24 at 11:58 AM, V10 (Assistant Director of Nursing) stated residents sitting at the same table should be fed at the same time so all the residents are eating together and so that one resident without food does not have to sit and watch the other residents eating their food. On 03/06/24 at 12:01 PM, V11 (Certified Nursing Assistant) stated…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-08 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 interview and record reviews the facility failed to refer one (R44) resident with newly evident or possible serious mental disorder to the appropriate state-designated authority in a total sample of 31 residents reviewed. Findings include: On 03/07/2024 at 12:19PM, V2 (Associate Administrator) states the hospital is responsible for completing the Level 1 Pre-admission Screening and Resident Review (PASARR) prior to a resident's admission to the facility. V2 states the facility ensures the resident has a Level 1 PASARR prior to admission because this ensures the facility receives payment. V2 states without the Level 1 screening, the facility cannot receive payment. V2 states if a resident has a mental health diagnosis upon admission, then the resident should have a Level 2 PASARR screening. V2 states she was not aware that the facility was responsible for referring residents for a Level 2 screening if a resident develops a mental health diagnosis after being admitted to the facility. R44's Face sheet…

    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 before2024-03-08 · 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, interviews and records review, the facility failed to change oxygen tubing and humidifier bottle weekly according to facility policy and failed to obtain a physicians order to continuously administer oxygen to one (R42) resident of six reviewed for oxygen in a sample of 31. Findings include: On 3/5/24 at approximately 11:50 AM, surveyor observed oxygen tubing/nasal cannula and humidifier bottle being used by R42. 2/22 (12 days prior to 3/5) was written on the humidifier bottle, there was no date on the nasal canula. On 3/5/24 at 12:00 PM, V16 (Registered Nurse) stated the oxygen tubing and humidifier bottle should be changed weekly. V16 stated it did not look like R42's oxygen tubing/nasal cannula and humidifier bottle had been changed within the week according to the date, 2/22, written on the bottle. V16 stated the tubing and bottle should be changed weekly for infection control. Since the nasal cannula is in the nose, if it is not changed appropriately, it is possible for the resident to breath in and catch something. On 3/7/24 at 11:36 AM, V3 (Director 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 before2024-03-08 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and review of records, facility failed to ensure expired medications are discarded from the medication cart for 2 (R57, R42) out of three residents reviewed for expired medications in a sample of 31. Findings include: On 03/05/24 at 12:32 PM surveyor checked through 3rd floor medication cart #1 and medication cart #2. On 3rd floor cart #2, surveyor observed R42's Flutcasone metered does inhaler with the dates, O: 1/21/2024, X: 3/3/2024. Surveyor asked V16 (Registered Nurse) was does O and X mean. V16 stated O mean opened and X mean expired. Surveyor asked for a copy for R42's metered dose medication label packet. After making a copy, surveyor observed V16 putting the medication back into the cart. Surveyor also observed R57's Anoro Ellipta Aerosol Powder opened but not dated on the packet. On 03/07/2024 at 11:30 AM, V2 (Director of Nursing) stated that once an inhalation medication is opened is should be dated. After Anoro Ellipta metered dose inhaler is opened, that medication is good for 6 weeks. V2 stated that medications are not effective after…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-08 · 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 date food items and discard expired food items in resident personal refrigerator for 1 (R118) resident reviewed in the sample of 7 for safe personal food storage. Findings include: On 03/05/24 at 12:33 PM, observed personal refrigerator in R118's room. R118 gave surveyor permission to look inside R118's refrigerator. Surveyor observed an opened 16-ounce container of Creamy Caesar Dressing with 25% left in the bottle dated with best by date 08/16/23. R118 said, I just had some of that the other day and it was okay. Observed numerous packages of different types of cheese (American, Swiss) in various zip lock bags not dated or labeled. On 03/05/24 at 12:45 PM, V6 (Registered Nurse) stated food in resident's personal refrigerators should be dated by the Certified Nursing Assistant and thrown out after three days. V6 stated the expiration dates listed a food product is followed and any expired items are thrown out so that the resident does not get sick by consuming the expired item. On 03/05/24 at 12:50 PM, V6…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-08 · 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, interviews and records review, the facility failed to maintain infection prevention protocols for one (R110) resident on contact precautions by not wearing proper personal protective equipment to render care. Findings include: On 3/5/24 at 11:30 AM, V15 (Registered Nurse) stated R110 is on transmission-based precaution for ESBL (extended spectrum beta lactamase) urine. 3/5/24 at 12:50 PM, observed a sign reading Contact Precautions on R110's door. Observed V20 enter R110's room with no PPE (Personal Protective Equipment) gown on. On 3/5/24 at 1:00 PM, V20 (Certified Nursing Assistant) stated V20 repositioned and checked R110's adult brief. V20 stated of course V20 had to touch R110 to complete those tasks. V20 stated R110 is on precaution and V20 is supposed to put on gloves and gown to go into R110's room. V20 stated V20 did not put on a gown because V20 did not have contact with fluids. I just repositioned and checked R110's brief. V20 stated the purpose for PPE is to protect self from infection. Without wearing the proper PPE there is a chance/possibility 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-06-02 · 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 observations, interviews, and record reviews the facility failed to follow their policy and procedure for food and supply storage to ensure foods in the main cooler were discarded after the expiration dates. This failure has the potential to affect 128 residents in the facility who are receiving oral diet. Findings Include: On 5/30/23 at 9:42 AM, during the initial kitchen tour with V5 (Food Service Supervisor), the following were found in the main cooler: cooked rice dated 5/22 with used by date of 5/28 and salmon patties with cooked date labeled as 5/22 with no used by date. V5 stated that these foods need to be discarded because they are passed the 7 days. V5 stated facility store leftover foods, prepared foods, dairies, vegetables, and meat in the main cooler. V5 stated that cooked foods are kept in main cooler for 7 days and then should be discarded. V5 stated that facility use the first in and first out method, which means that whatever is in first it should be used first. V5 stated that all expired foods and dairies are discarded and should not be served to 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 before2023-06-02 · tag F0550 — failed to protect resident dignity and rights — pattern
    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 observations, interview, and record review, the facility failed to ensure residents (R15, R47, R50, R55) were treated with dignity and serve meals at the same time for 4 of 14 residents reviewed for the dining task. Findings include: On 05/30/2023 at 11:45 AM, multiple staff were passing out the lunch trays for the second floor. R15, R47, R50 and R55 were sitting in the same table for lunch. R50 had a lunch tray while R15, R47, and R55 did not. R15, who was sitting to R50's left side, reached for R50's coffee on the lunch tray and drank it without asking permission. At 11:48 AM, V6 (Nurse) dropped off R55's lunch tray. R15 and R47 did not receive their lunch trays. At 11:55 AM, R15 and R47 remained without lunch trays. R47 tried to get staff's attention by saying Hey and trying to make eye contact with staff. R47 extended right arm out to V9 (Activity Aide) when [V9] passed by but did not get V9's attention. At 11:56 AM, R47 stated loudly I'm hungry. V9 heard and stated you're hungry? Let me look for your tray. Shortly after, V10 (Certified Nurse Aide) brought R47's lunch…

    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 before2023-06-02 · 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 observations, interviews, and record reviews the facility failed to a.) discard expired medications from medication cart for three (R72, R88, R112) residents and b.) ensure that medications are properly labeled for one (R133) resident. These failures have the potential to affect four (R72, R88, R112, R133) residents to facilitate consideration of precautions and safe administration of medications reviewed for medication storage and labeling in 2 of 4 medication carts inspected in a sample of 62 residents. The findings include: On 5/31/23 at 2:56 pm V20 (Registered Nurse - RN) stated that she has been working in the facility for 10 years. Surveyor inspected 1st floor medication cart with V20. Observed R72 Humalog insulin multi dose vial labeled with date opened 4/30/23; expired 5/28/23. Observed R88 Azelastine Nasal spray labeled with open date 3/30/23; expiration / discard date was not labeled. V20 stated nasal spray should be discarded in 30 days after opening. Observed R112 Glargine insulin pen labeled Expired date: 5/25/23, open date was not labeled. Observed R133…

    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 · D2023-06-02 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, and record reviews the facility failed to ensure or establish mechanisms for documenting and communicating to interdisciplinary team regarding code status. This failure has the potential to affect one (R99) of one resident reviewed for advance directive in a sample of 26. The findings include: R99 admission date was on 11/5/22 with diagnoses not limited to Alcoholic cirrhosis of liver without ascites; Venous insufficiency; Peripheral vascular disease; Essential hypertension; Type 2 diabetes mellitus; Iron deficiency anemia; Osteoarthritis; Gastro-esophageal reflux disease; Hyperlipidemia; Vitamin B deficiency; Dysphagia, oropharyngeal phase; Major depressive disorder; Insomnia. On 6/1/23 at 10:27 am V32 (Social Service Coordinator) was interviewed and stated she is working in the facility 3 times per week. V32 stated that there is a social worker consultant working remotely who is available anytime when there is any social service concerns or issues. V32 stated that she is responsible in completing resident's minimum data set (MDS) assessments and care plans…

    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 before2023-06-02 · 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 observations, interviews, and record reviews the facility failed to follow policy for oxygen therapy to ensure that oxygen nasal tubing and humidifier be changed weekly and when oxygen tubing is not in active use be stored in plastic bag. These failures have the potential to affect one (R118) of one resident reviewed for respiratory care in a sample of 26. The findings include: R118 admission date was on 12/28/22 with diagnoses not limited to Malignant neoplasm of unspecified part of unspecified bronchus or lung; Chronic obstructive pulmonary disease; Unspecified asthma; Secondary malignant neoplasm of bone; Atherosclerotic heart disease; Cardiomyopathy; Chronic kidney disease, stage 3B; Hypertensive heart disease with heart failure; Chronic pulmonary embolism; Heart failure; Essential hypertension; Spinal stenosis, lumbar and cervical region; Alcohol abuse; Nicotine dependence. On 5/31/23 10:29 AM Observed R118 lying on bed, on moderate high back rest, alert and verbally responsive. Observed oxygen concentrator machine was going on at 2L/min. Observed oxygen nasal tubing…

    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 · D2023-06-02 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews the facility failed to follow policy for residents on aspiration precautions to ensure that prescribed type of liquid consistency must be followed. This failure has the potential to affect one (R99) of six residents reviewed for nutrition in a sample of 26. The findings include: R99 admission date was on 11/5/22 with diagnoses not limited to Alcoholic cirrhosis of liver without ascites; Venous insufficiency; Peripheral vascular disease; Essential hypertension; Type 2 diabetes mellitus; Iron deficiency anemia; Osteoarthritis; Gastro-esophageal reflux disease; Hyperlipidemia; Vitamin B deficiency; Dysphagia, oropharyngeal phase; Major depressive disorder; Insomnia. On 5/31/23 at 11:46 am V21 (Certified Nurse Assistant - CNA) was observed assisting R99 at lunch meal in R99's room. V21 placed a clothing protector to R99. Observed R99 head of bed was elevated. Observed lunch tray with pureed food consisting of pasta, green peas, mushroom soup, and dessert. Observed with thickened coffee and thickened water in a cup. Observed a carton…

    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 · D2023-06-02 · tag F0810 — isolated
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to provide adaptive feeding equipment for 1 (R104) of 6 residents reviewed for adaptive equipment usage in a total sample of 130. Findings include: On 05/30/23 at 11:39 AM, surveyor observed R104 feeding self in unit dining room with left hand, right hand was in a splint. R104 observed eating from a regular plate, not a divided plate, or a partition plate. There was no plate guard on the regular plate. Observed food spilling from R104's plate onto R104's tray. R104's meal ticket had Plate Guard written on it. On 05/31/23 at 11:53 AM, V23 (Occupational Therapist) stated R104 can feed self with left hand but does not have use of R104's right hand. V23 stated the nursing staff had referred R104 to V23 because they noticed R104 was having a harder time feeding himself. V23 stated R104 was observed to be having trouble getting enough food onto the spoon and keeping the food on the spoon during the feeding process. V23 stated a plate guard 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2025-04-03 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, and record reviews, the facility failed to provide the required square footage of 80 square feet per resident for multiple resident bedrooms for 19 (111, 113, 114, 115, 116, 118, 121, 122, 210, 211, 212, 214, 215, 217, 311, 313, 315, 317, 325) rooms out of 86 rooms in the facility. This failure affected 29 (R5, R14, R18, R27, R44, R46, R49, R53, R54, R58, R59, R60, R64, R72, R78, R80, R82, R83, R89, R103, R106, R110, R116, R123, R125, R126, R130, R133, R134) residents in the total sample of 75 residents. Findings include: On 03/31/2024 at 9:51am, during the entrance conference with V3 (Administrative Consultant). V3 stated we have a waiver for our room sizes. We do this waiver every year. On 04/01/2025 at 10:55am, V18 (Associate Administrator) we have rooms that have less than the required square footage for each resident. Each room has 2 certified beds. We ensure all the required furnishing and equipment for these residents are met, and these are included in our plan of correction. We did not make any repairs or construction since the last annual survey. 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2024-03-08 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interview and record review, the facility failed to provide the required 80 square feet per bed for 19 resident's rooms out 86 rooms in the facility. This failure has the potential to affect 26 (R138, R16, R111, R41, R52, R130, R342, R86, R139, R12, R91, R72, R119, R114, R51, R44, R129, R127, R90, R88, R134, R61, R126, R109, R58, R24) residents in a sample of 144 residents. Findings include: On 03/05/24-03/08/24 during the facility tour on the first, second and third floors, observations were made of room sizes. On 3/6/2024 at 12:33pm, V1 (Administrator) said there are 19 rooms that do not measure 80 square feet per resident. V1 stated the furniture in those rooms is arranged to make sure there is space for the residents and some of the considerations the administrative team does is to consider the residents who will occupy these rooms to make sure they can be comfortable in these rooms because the bed sizes are smaller, and ambulatory status of the residents is considered. V1 stated no resident, or their family members have complained about the room size, 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.

    Environmental Deficiencies · Waiver has been granted
  • No harm found · Bcited before2023-06-02 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interview and record review, the facility failed to provide the required 80 square feet per bed for 20 resident's rooms out 196 rooms in the facility. This failure has the potential to affect 20 [R14, R18, R23, R24, R29, R58, R63, R66, R73, R93, R96, R98, R103, R105, R115, R123, R128, R130, R284, R285] residents in a sample of 62 residents. Findings include, On 5/30/23-6/2/23 during the facility tour on the first, second and third floors, observations were made of room sizes. On 5/30/23 at 10:10 AM, V2 [Assisted Administrator] stated, There are 19 rooms that do not measure 80 square feet per resident. Administration team always monitor the rooms to ensure there is space for each resident personal items and adaptive equipment. The 21 residents or family members have not complained about their room space. I submit a waiver every year. On 5/30/23 at 11:23 AM, V26 [Maintenance] stated, No construction or modification has been made to the 20 rooms at this time. This is an old building and there is no additional space to increase those rooms in size. R18, R285, R23,…

    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.

    Environmental Deficiencies · Waiver has been granted

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to MARQUIS HEALTH SERVICES — 87 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 53.0+1.0 vs chain
Health inspection 4 of 52.6+1.4 vs chain
Staffing 3 of 52.3+0.7 vs chain
Quality measures 3 of 54.3-1.3 vs chain
The other 86 homes this chain runs (chain average 3.0★, per CMS)
1 of 5Avalon Rehabilitation And Healthcare CenterHamilton, NJ 1 of 5Bay Harbor Post Acute Healthcare CenterSalisbury, MD 1 of 5Blueberry Hill Rehabilitation And Healthcare CtrBeverly, MA 1 of 5Canterbury Rehabilitation And Healthcare CenterRichmond, VA 1 of 5Cape Cod Post Acute CareBrewster, MA 1 of 5Crest Pointe Rehabilitation And Healthcare CenterPt Pleasant, NJ 1 of 5Highland Park Rehabilitation And Healthcare CenterChelsea, MA 1 of 5Mount Holly Rehabilitation & Healthcare CenterLumberton, NJ 1 of 5Nashua Post Acute CareNashua, NH 2 of 5Arbor Ridge Rehabilitation And Healthcare CenterWayne, NJ 2 of 5Atlantic View Post AcuteNewport News, VA 2 of 5Bayview Rehabilitation and Healthcare CenterNorth Kingstown, RI 2 of 5Collingswood Rehabilitation And Healthcare CenterRockville, MD 2 of 5Elmhurst Rehabilitation and Healthcare CenterProvidence, RI 2 of 5Graduate Post AcutePhiladelphia, PA 2 of 5Heritage Hills Nursing & Rehabilitation CenterSmithfield, RI 2 of 5Laurel Brook Rehabilitation And Healthcare CenterMount Laurel, NJ 2 of 5Lawrence Rehab & Hcc/The Meadows At LawrenceLawrenceville, NJ 2 of 5Lawrence Rehabilitation HospitalLawrenceville, NJ 2 of 5Lighthouse Rehabilitation And Healthcare CenterRevere, MA 2 of 5Lincolnwood Rehabilitation and Healthcare CenterNorth Providence, RI 2 of 5North End Rehabilitation And Healthcare CenterBoston, MA 2 of 5Orchard Hill Rehabilitation And Healthcare CenterTowson, MD 2 of 5Palm Springs Post AcuteChelmsford, MA 2 of 5Riverview Healthcare CommunityCoventry, RI 2 of 5Roosevelt Rehabilitation And Healthcare CenterPhiladelphia, PA 2 of 5Southampton Rehabilitation And Healthcare CenterRichmond, VA 2 of 5Springfield Rehabilitation And Healthcare CenterSpringfield, PA 2 of 5West Chester Rehabilitation And Healthcare CenterWest Chester, PA 2 of 5Westgate Hills Rehab & Healthcare CtrBaltimore, MD 2 of 5Willow Brook Rehabilitation And Healthcare CenterWilmington, MA 2 of 5YORK Post AcuteYorktown, VA 3 of 5Alexandria Rehabilitation And Healthcare CenterAlexandria, VA 3 of 5Aspen Hill Rehabiliation & Healthcare CenterHaverhill, MA 3 of 5Belmont Bay Rehabilitation And Healthcare CenterWoodbridge, VA 3 of 5Brighton Post Acute CareBrighton, MA 3 of 5Cambridge Rehabilitation And Healthcare CenterMoorestown, NJ 3 of 5Capitol Rehabilitation And Healthcare CenterHarrisburg, PA 3 of 5Chelsea Rehabilitation And Healthcare CenterGoochland, VA 3 of 5Exton Post AcuteExton, PA

Showing 40 of 86; 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
KOHN 2020 DESCENDANTS' TRUSTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF49%since 12/31/2020
KOHN 2020 FAMILY TRUSTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF49%since 12/31/2020
KOHN, CHARLOTTEIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2020
PEDDINGHAUS, WOLFIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2020

CMS files one row per role, so the 9 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$14.1M
Net patient revenuemost recent cost report
+12.8%
Operating marginrevenue minus expenses
$936K
Related-party expense8% of expenses
Who pays — share of resident-days
Medicaid 94%Medicare 6%Other / private 0%

About 94% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $936K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$252per resident / day
operating cost
$7,657per month
≈ monthly operating cost
$289per 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 145532. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-03, 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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