Birchwood Plaza
1426 West Birchwood, Chicago, IL 60626 · For profit - Corporation · 200 certified beds · (773) 274-4405 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- 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
- it has 1 actual-harm citation
- a high number of inspection citations overall (31) — 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.
| 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
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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.
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 | 15.7% | 13.4% | 15.4% | typical |
| Long-stay residents who lose too much weight | 3.3% | 6.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.9% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 4.2% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 100.0% | 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 | 2.1% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 11.2% | 14.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 6.0% | 18.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.0% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.0% | 4.8% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 21.1% | 20.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 17.2% | 21.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 4.1% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 59.5% | 63.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 19.2% | 26.1% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 12.6% | 13.9% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.78 | 2.02 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.19 | 2.22 | 1.80 | better |
‡ 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.
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 0.14 therapist hours per resident per day in 2025Q4 — more than 11% of the 13,714 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 21% 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 14% — 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 | 42.1%CMS range 29.9–54.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.4%CMS range 6.8–14.5 | 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 | 75.4% | 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 | 77.0% | 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 | 55.7% | 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 | 98.8% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 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 | 0.0% | 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 | 8.5%CMS range 4.9–14.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.99 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 200 beds and averages 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 2.88 hrs/resident/day on weekends vs 3.07 on weekdays — 6% thinner on weekends. RN hours go from 0.82 to 0.64 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
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.
31 citations, most serious first. The 11 most serious are shown; the remaining 20 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 — 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 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.
- Potential for harm · Fcited before2026-02-10 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to follow their policies by a) not ensuring all food items in the kitchen were labeled/dated, b) having expired food items in the kitchen, c) not recording temperatures for the refrigerators, freezers, dishwasher, and d) not following manufacturer instructions to use the three-compartment sink. This failure has the potential to effect 135 residents that eat food from the kitchen.Findings include:2/4/26 at 10:07 AM, toured facility kitchen with V18 (Food Service Supervisor) and observed:-a pan in the refrigerator labeled gelatine with prep date 1/27/26 and use by date 2/2/26-bucket of corn flake crumbs labeled with no prep date or opened date and use by date 12/30-bucket with rice inside labeled breadcrumbs with prep date 1/19/26 and use by date 1/23/26-a pan in the refrigerator covered with aluminum with meat balls/hamburgers 1/30/26 written on it. No indication if 1/30/26 is the date placed in the refrigerator or the date to discard.-a 55lb bag of Pizzeria Wheat Flour labeled 013125. V18 stated it was supposed…
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 · D2026-02-10 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain dignity for one (R93) of three residents reviewed for dining services in a sample of 27.R93 is a [AGE] year-old individual whose current face sheet includes medical diagnosis but not limited to: unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, other diseases of pharynx.MDS (Minimum Data Set) section c- cognitive status dated 12/16/2025 documents R93's brief interview for mental status (BIMS) as 4/15, indicating R93 has severe cognitive disabilities. section gg-self-care dated [DATE], documents R93 requires supervision touching assistance. On 02/04/2026 at 12:21PM, R93 was observed eating lunch dosing on and off. V8 (Certified Nursing Assistant -CNA) was observed going into R93's room, woke R93 and asked R93 if she wanted assistance with eating her food. R93 nodded her head yes. V8 stood over R93 and started feeding R93. V8 stated she is supposed to sit down while…
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 · D2026-02-10 · 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
Based on observations, interviews, and record reviews the facility failed to follow their policy on resident's unable to use a call light by posting the lighthouse sign outside the room for one (R32) in a total sample of 27 residents reviewed.Findings include: R32's Minimum Data Set (MDS) dated on January 6, 2026, Brief Interview Score of 10, indicates that R32 is moderately cognitively impaired. Care plan with review date of 10/13/2025 documents in part, R32 is not able to use a call light. Purposeful rounding will be observed. Lighthouse posted outside room with bed number. On 02/04/2026 at 12:10 PM, Surveyor observed R32 sitting in her chair while finishing up her lunch. R32 is well groomed, appears to be calm and in a good mood. R32 appears to be comfortable and free of pain. R32 is alert and oriented to person with confusion of place and time. Surveyor did not observe the light house sign inside or outside R32's room. On 02/04/2026 at 12:12 PM, R32 stated she has concerns with staff not coming to help her when she needs them. Surveyor asked R32 if she utilizes the call light…
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 · D2026-02-10 · tag F0578 — failed to honor advance directives / code status — isolatedHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure advance directive or code status is consistent with the comprehensive care plan of one (R17) out of six residents reviewed for advance directive in a sample of twenty-seven. Findings Include: R17's Minimum Data Set (MDS) dated [DATE] shows she is moderately cognitively impaired. R17's Electronic Medical Record (EMR) revealed she was initially admitted to the facility on [DATE] and she is [AGE] years old with diagnoses not limited to malignant neoplasm of unspecified site of unspecified female breast, iron deficiency anemia secondary to blood loss (chronic), other cerebral infarction, post-traumatic stress disorder, hypertensive heart disease without heart failure, and moderate persistent asthma with status asthmaticus. Physician Order Sheet active order as of [DATE] revealed; Do Not Resuscitate/DNR dated [DATE]. On [DATE] at 10:07 AM, R17 stated that her code status is DNR because she has lived for seventy-six years, and she would like 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 · D2026-02-10 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain medical records confidentiality for one (R29) of three residents reviewed in a sample of 27.R29 is an [AGE] year-old individual whose current face sheet documents medical diagnosis to include but not limited to type 2 diabetes mellitus with hypoglycemia without coma, chronic kidney disease, unspecified, unspecified osteoarthritis, unspecified site. MDS Section C - Cognitive Patterns documents R29's Brief Interview for Mental Status (BIMS) as 10/15 indicating R29 has moderate cognitive impairment.On 02/04/2026 at 12:25PM, V4's computer was observed on team one's medication cart in the middle of hallway with R29's personal health records (Medication administration Record) visible to anyone passing by the hallway. V4 (registered Nurse) was observed away from her computer standing near the dining room talking to a resident family member. V4 stated she was approximately 12 feet away from her computer and should have locked her computer…
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 · D2026-02-10 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
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 record review and interview, the facility failed to follow the Resident Assessment Instrument (RAI) manual to ensure timely submission of the Minimum Data Set (MDS) assessments for three (R5, R38, and R131) out of eight residents reviewed in a total sample of twenty-seven.Findings Include:Resident R5's annual MDS assessment dated [DATE] was submitted on 01/31/26.Resident R38's quarterly MDS assessment dated [DATE] was submitted on 01/31/26.Resident R131's quarterly MDS assessment dated [DATE] was submitted on 01/31/26, all exceeding the 14-day submission requirement.On 02/06/26 at 2:28 PM, V3 (Director of Nursing) stated that she is responsible for completing the Resident Minimum Data Set (MDS) assessments, ARD stands for the assessment reference date and that is when the assessment is due. She stated that fourteen days from the ARD, the completed assessment must be submitted to the federal agency. The accepted date posted on R5, R38, and R131 reflects the assessment was submitted to the federal agency…
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 before2026-02-10 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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 acquire preadmission screening and resident review for 1 out of 7 residents (R12) in a total sample of 27 resident reviewed for resident assessment. These failures affect 1 resident (R12) in determining correct care settings for a resident with serious mental illness.Findings include:R12's MDS (minimum data set) dated on December 24, 2025, Brief Interview Score (BIMS) of 5, indicates that R12 is severely cognitively impaired.On 02/05/2026 at 11:24 AM, during record review for preadmission screening and resident review (PASRR) documents in part, short term approval without specialized services. Date of determination: April 5th, 2025. Date short term approval ends: August 3, 2025. On 02/06/2026 at 9:00 AM, V2 (Associate Administrator) stated the new PASRR Determination report was run today at 7:02 AM. V2 stated R12 does not require specialized services. V2 stated the results will be available to view on Monday 02/09/2026.On 02/06/2026 at 9:51 AM, V13 (Office Manager) stated it is important to follow up with 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 · D2026-02-10 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to have a person-centered care plan that is consistent with the resident's current condition, goals, and services for one (R84) resident out of eight residents reviewed in a total sample of 27 residents. This failure places residents at risk to be provided with inappropriate care and services to meet the resident's physical, mental and/or psychosocial needs. On 02/04/2026 at 12:50 PM, R84 was sitting on specialized chair, with a call light button, a red string attached to her right upper arm, on part of the gown. R84 noted to be very hard of hearing. Not able to hear. R84 asked this surveyor to grab R84's hair. This surveyor attempted to explain to R84 that she cannot assist her but will find someone to come and help her. R84 stated I didn't hear that, I try to read their lips. On 02/06/26 at 11:15 AM, V14 (Social Worker) stated that R84 is having a hard time of hearing, she can understand, when you talk to her, you have to talk to her closely…
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 before2026-02-10 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 ensure that one (R3) resident who depends on staff assistance for their ADL (Activities of Daily Living) care received shaving out of eight residents reviewed in a total sample of 27. This failure places residents at risk of being provided with inappropriate care and services to meet the resident's physical, mental and/or psychosocial needs. On 02/04/2026 at 12:25 PM, R3 was noted with facial hair on her chin. R3 stated that she takes showers and staff assist her. R3 stated that staff have not removed R3's facial hair. R3 stated that she was not sure if they were rushing or not. R3 appears calm and cooperative, no behaviors noted. R3 noted with her head shaking a little. On 02/05/26 at 1:55 PM, R3 sitting on a chair, next to R3's bed, wearing own clothes, not shaved, still with facial hair on her chin. R3 preferred to speak in Spanish. R3 stated that no staff have come to ask R3 if she wanted to be shaved. R3 stated that she feels bad with…
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 before2026-02-10 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to a.) ensure staff followed contact isolation precautions to prevent spread of infections for one (R81) of three residents reviewed b.) ensure that its staff follow the facility's policy and maintain clean technique/infection control practice while performing incontinence care to one (R8) resident out of eight residents reviewed in a total sample of 27. R81's current face sheet documents medical diagnosis to include but not limited to: sepsis, unspecified organism, cystitis, unspecified with hematuria, personal history of urinary (tract) infections, type 2 diabetes mellitus with unspecified complications, pneumonia, unspecified organism, other specified disorders of bladders of bladder. MDS (Minimum Data Set) section C-(Cognitive abilities) dated [DATE], documents R81's Brief Interview for Mental Status (BIMS) as 10/15, indicating R29 has cognitive moderate impairment. R81's Physician Order Sheet POS) dated 2/2/026 documents: Contact…
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 20 citations
- Potential for harm · Ecited before2025-04-03 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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.
- Potential for harm · Ecited before2025-04-03 · 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 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.
- Potential for harm · Dcited before2025-04-03 · tag F0644 — isolatedCoordinate 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.
- Potential for harm · Dcited before2025-04-03 · tag F0645 — isolatedPASARR 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.
- Potential for harm · Dcited before2025-04-03 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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.
- Potential for harm · D2025-04-03 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure 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.
- Potential for harm · Dcited before2025-04-03 · 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
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.
- Potential for harm · Ecited before2024-12-26 · 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 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.
- Potential for harm · Ecited before2024-12-26 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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.
- Potential for harm · Fcited before2024-03-08 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on 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.
- Potential for harm · F2024-03-08 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure 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.
- Potential for harm · Dcited before2024-03-08 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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.
- Potential for harm · Dcited before2024-03-08 · tag F0644 — isolatedCoordinate 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.
- Potential for harm · D2024-03-08 · 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
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.
- Potential for harm · D2024-03-08 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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.
- Potential for harm · D2024-03-08 · tag F0813 — isolatedHave 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.
- Potential for harm · Dcited before2024-03-08 · 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, 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.
- No harm found · Bcited before2026-02-10 · tag F0912 — patternProvide 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 26 (R13, R18, R28, R34, R36, R46, R49, R50, R57, R60, R67, R77, R84, R85, R90, R93, R94, R97, R99, R107, R109, R114, R125, R138, R139, R151) residents in the total sample of 137 residents.Findings include:On 02/04/2026 at 10:15 AM, V2 (Associate Administrator) stated the facility has a room waver for resident rooms that are less than 80 square feet for multiple residents and the 100 Square feet for single resident room. V2 provided a copy of a list of rooms that are included on the waiver.The (02/10/2026) email correspondence with V18 documented, in part The facility has an annual Waiver for Resident bedrooms that do not measure 80 square feet per resident in multiple residents bedrooms.The (02/10/2026) Waiver of 42 CFR 483.90. Physical Environment documented, 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.
- No harm found · Bcited before2025-04-03 · tag F0912 — patternProvide 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.
- No harm found · Bcited before2024-03-08 · tag F0912 — patternProvide 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to MARQUIS HEALTH SERVICES — 90 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.1 | +0.9 vs chain |
| Health inspection | 4 of 5 | 2.6 | +1.4 vs chain |
| Staffing | 3 of 5 | 2.3 | +0.7 vs chain |
| Quality measures | 3 of 5 | 4.4 | -1.4 vs chain |
The other 89 homes this chain runs (chain average 3.1★, per CMS)
Showing 40 of 89; 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| KOHN 2020 DESCENDANTS' TRUST | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 49% | since 12/31/2020 |
| KOHN 2020 FAMILY TRUST | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 49% | since 12/31/2020 |
| KOHN, CHARLOTTE | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2020 |
| PEDDINGHAUS, WOLF | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 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.
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
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 2026-09-01 — CMS provider number 145532. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-10, 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.