Little Sisters Of The Poor
2325 North Lakewood Avenue, Chicago, IL 60614 · Non profit - Corporation · 76 certified beds · (773) 935-9600 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (32% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2023
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $9,272 in federal fines (most recent 2025-03-07)
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) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 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 | 18.2% | 13.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 9.2% | 6.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.0% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.6% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 20.5% | 54.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 1.1% | 0.1% | 0.1% | worse |
| Long-stay residents with falls causing major injury | 2.8% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 17.1% | 14.3% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 10.9% | 18.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 9.0% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 26.1% | 20.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 4.1% | 21.7% | 17.1% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.29 | 2.02 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.48 | 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.
Therapy staffing: this home’s payroll records show 0.15 therapist hours per resident per day in 2026Q1 — more than 12% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 17% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 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 next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 76 beds and averages 44.9 residents a day — about 59% occupied, or roughly 31 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 4.30 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.96 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.81 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.74 hrs/resident/day on weekends vs 4.52 on weekdays — 17% thinner on weekends. RN hours go from 1.06 to 0.71 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 32% 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.
22 citations, most serious first. The 12 most serious are shown; the remaining 10 are one tap away and print in full.
- Actual harm · Gcited before2025-05-01 · 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 (R1) using a mechanical lift during bedside care. This failure affected one resident (R1) causing R1 to sustain a fracture of the distal shaft of the fifth metatarsal and pain in left hand fifth metatarsal. Findings include: R1 has a diagnosis which includes but are not limited to unspecified abnormalities of gait and mobility and paralytic gait. R1 has a Brief Interview of Mental Status (BIMS) dated 03/17/25 documents that R1 has a BIMS score of 08 which indicates that R1 has some cognitive impairments. R1's Initial/Final Report to the surveying state agency dated 01/15/25 at 8:05 am documents in part: Date, Time, location of Injury: 01/12/2025, 3:50 pm, Residents bedroom. Based on the initial and final investigation, review of the medical record, and interview of witnesses during the event, the following are the known facts at this time on 1/12/2025 at 3:50 pm, nurse informed by CNA (Certified Nursing Assistant) that when…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-08-29 · 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 upon observation, interview, and record review the facility failed to ensure that (R1's) care plan was congruent with the fall risk assessment, failed to implement fall prevention interventions and failed to provide supervision to three of three residents (R1, R2, R3) reviewed for falls. These failures resulted a laceration to the left lower leg from R1's 6/25/24 fall. These failures also resulted a laceration, abrasion, and bruises to the forehead, bridge of nose, and both arms along with a C1 fracture from R1's 7/13/24 fall. Findings include: 1.) The facility's fall incident log affirms R1 fell on 6/25/24 and 7/13/24. R1's (6/25/24) incident report states Unwitnessed Fall. Called to resident room by CNA (Certified Nursing Assistant). Upon entering resident room noted sitting on her bottom with both legs extended out in front of her, with hands palm side down with upper body erect next to closet. Noted moderate amount of blood from open old wound on lower inner left leg. Resident states she was getting…
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 before2025-03-07 · 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 proper sanitation and food storage practices as evidenced by a.) food not properly labeled, b.) food not properly stored, c.) equipment used for food preparation not properly sanitized, and d.) dishwasher temperatures not reaching at least 160 degrees Fahrenheit during the wash cycle. These deficient practices have the potential to affect all 43 residents receiving food prepared in the facility kitchen. Findings include: On 03/04/2025 at 9:39 AM during initial kitchen tour with V7 (Dietary Manager), the following food items were found in the dairy walk-in cooler: 1. 1 package of opened cream cheese wrapped in clear plastic wrap, no open date, no expiration date or use by date labeled on cream cheese. The following food items were found in the prep walk-in cooler: 1. 7 containers of pureed fruit cups individually wrapped in clear plastic wrap, no preparation date, or use by date labeled on fruit cups. 2. 1 round sheet cake labeled with an expiration date of 03/01/2025. 3. 1 box of lettuce and tomatoes…
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 · E2025-03-07 · tag F0644 — patternCoordinate 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 review, the facility failed to refer four (R1, R23, R30, R35) out of twelve residents with newly evident or possible serious mental illness to the appropriate state-designated authority for review. Findings include: On 03/06/2025, at 3:50 PM, V3 (Social Services Director) states all residents require a level I PASARR to determine if the nursing home is the correct setting for the resident to live in. V3 states she is responsible for making sure Level 1 Pre-admission Screening and Resident Review (PASARR) are in the residents' records. V3 states she is responsible for all PASARR screenings in the facility. V3 states when the new screening agency requirements were implemented approximately 2 years ago, V3 states she entered the residents' information into the new system. V3 states she is responsible for putting in demographics such as the residents' social security number, their diagnoses, their date of birth , and their name. V3 states she is not sure if she entered residents'…
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 · E2025-03-07 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to adhere to nursing standards of practice by preparing/pre-cupping medications and documenting in advance of administration for four (R5, R15, R19, R20) of 5 residents reviewed for medications in a total sample of 12. Findings include: On [DATE] at 8:50 AM, reviewed second floor medication room with V5 (Registered Nurse) observed: - three medication cups with medications in them and a name printed on the cup - one medication cup with crushed medications and apple sauce in it and a name printed on the cup 1.) R5's physician order summary provided by facility reads in part: diltiazem HCL oral tablet 120mg three times a day for hypertension, hydralazine HCL oral tablet 25 mg three times a day for hypertension, Lasix oral tablet 20mg in the morning for hypertension, losartan potassium oral tablet 100mg one time a day for hypertension, metoprolol tartrate oral tablet 50mg two times a day for hypertension. 2.) R15's physician order summary…
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 before2025-03-07 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure expired medications were not available to administer to residents. This failure has the potential to affect all residents that receive medications from the first-floor medication cart and the second-floor medication room. Findings include: On 3/4/25 at 10:00 AM, reviewed first floor medication cart with V4 (Registered Nurse) observed: - geri-lanta antacid/antigas with expiration date 02/25 - calcium 600mg with expiration date 02/25 - folic acid 400mcg with expiration date 02/25 - centrum silver with expiration date 02/24 On 3/5/25 at 8:50 AM, reviewed second floor medication room with V5 (Registered Nurse) observed: - vitamin C 500mg with best by date 02/25 - five bottles of Glucerna with expiration date [DATE] On 3/4/25 at 10:26 AM, V4 (Registered Nurse) stated there should not be expired medications in the medication cart or medication room. It is believed that expired medications have lost their potency. The expired medication…
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 · E2025-03-07 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to have an appropriate policy and procedure to ensure residents are offered a pneumococcal immunization. The facility also failed to offer and provide pneumococcal vaccination for 5 residents (R6, R23, R31, R32 and R40) out of 5 in a sample of 12. Findings include: On 03/06/2025 at 9:29 AM, V2 (Director of Nursing) states that she is the infection preventionist nurse and manages residents' immunization records. V2 states that she keeps the resident's immunization record in their electronic medical record (EMR) under immunization tab and she also uploads the consents in their EMR. V2 reports that every year they do the flu and Covid-19 vaccines. Right now, they are working on getting the Pneumococcal vaccine clinic set up. V2 states that when there is a new admission, their immunization record is checked and if they need a recommended vaccine, the facility offers it. V2 states that it is documented in the resident EMR if the resident refuses. V2 states…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-07 · 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 interview and record review, the facility failed to clearly document the code status for one (R35) of 5 residents reviewed for advance directives in a total sample of 12. Findings include: Record review of R35's physician orders in the electronic medical record revealed R35 had three active advance directive orders, one order for full code dated [DATE], one order for CPR (cardiopulmonary resuscitation) dated [DATE] and one order for DNR (do not resuscitate) dated [DATE]. When reviewing R35's electronic record, writer clicked a hyper link reading (Advance Directives). The writer was taken to three documents, one being a IDPH Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form, dated [DATE], and designating Do Not Attempt Resuscitation/DNR. No form designating full code was observed. On [DATE] at 1:28 PM, V2 (Director of Nursing) stated there are two code status, DNR (do not resuscitate) or CPR (cardiopulmonary resuscitation)/full code. Writer showed V2 two active orders in R35's…
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 · D2025-03-07 · 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 review of records and interview the facility failed to follow resident assessment instrument (RAI) related to discharge assessment within the required timeframe after discharge for one (R39) out of four residents for a total sample of 12 residents. This failure resulted failure of completion and/or submission that causes errors on report. Findings include: R39 was initially admitted on [DATE] and was discharged on [DATE]. Per R39's record there was no discharge assessment done after [DATE]. Per record latest assessment of R39 was done on [DATE]. No other assessment was done after [DATE]. On [DATE] at 1:07 PM, V11 (MDS (Minimum Data Set) coordinator/Registered Nurse) states that she has worked for the facility for over 10 years as the MDS coordinator. This surveyor asked V11 when she completes the MDS discharge assessment. V11 states that it depends, in several cases, the residents first came from the community as Medicare A and B, and they discharged back to the community. We have 14 days to complete…
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 before2024-02-08 · 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 observation, interview and record review the facility failed to discard food items that were beyond their use by dates. This failure has the potential to affect all 42 residents that receive oral nutrition residing in the facility. Finding include: On 2/5/2024 at 9:20am surveyor observed 3 unopened 1/2 gallons of buttermilk with a yellow sticker dated 11/03/2023 and an unopened one gallon of 2% milk with a use by date of 1/16/2024. On 2/05/2024 at 9:28am V8 (Dietary Manager) stated that it (the milk) should have been thrown out. On 2/05/2024 at 9:30am surveyor observed 2 aluminum pans of cooked Lasagna with a date of 1/18/2024 in the freezer. On 2/5/2024 at 9:35am V8 stated that it was donated on that date, but it should have been discarded by now. On 2/5/2024 at about 9:45am surveyor observed 5 unopened and 1 open box of Chocolate frosting mix with a date of 7/4/2022. On 2/5/2024 at 9:50am V8 stated these items should have been tossed a while ago. Reception and use of Food Items with a review date of 1/2015 documents, in part, documents commercially packaged goods will be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-08 · 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, interview and record review, the facility failed to date oxygen tubing per resident's physician order. This failure affected one resident (R24) reviewed for oxygen equipment, in a total sample of 30 residents. Findings include: On 02/05/2024 at 11:41 am, surveyor observed R24 sitting in the chair in R24's room, awake and alert. R24 was observed with oxygen concentrator machine set at 3 ½ liters oxygen. The nasal cannula was observed placed in R24's nares, nasal cannula was connected to oxygen tubing and tubing was connected to the oxygen concentrator machine, the tubing was not dated. When R24 was asked regarding R24's oxygen tubing, R24 stated, I have been on oxygen for a while and the staff changes the tubing once a month. On 02/07/2024 at 10:30 am V2(DON/Director of Nursing) stated the nurses are responsible for changing the oxygen tubing. V2 stated the oxygen tubing should be changed every Sunday, at least weekly on the 11pm to 7am shift. V2 stated the nurses should label the oxygen tubing with a date which would indicate when the oxygen tubing was changed.…
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 before2024-02-08 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
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 a medication administration error rate of <5% for 2 (R16 and R31) residents of 6 residents reviewed for medication administration. There were 28 opportunities and 2 errors resulting in 7.14% medication administration error rate. Findings include: 1.) On 02/06/2024 at 9:09am, during the medication administration task with V3 (Registered Nurse), observed V3 dispensed O D Multivitamins with mineral 1 tablet for R31. On 02/06/2024 at 9:45am, this surveyor requested V3 to check the container of the O D* and stated it is multivitamins with minerals. The color is light orange. This is an error. R31's (Active order as of: 02/06/2024) documented, in part Multivitamin Oral Tablet give 1 tablet by mouth one time a day. R31's (Active order as of: 02/06/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) cerebral infarction, age-related cognitive decline. Order Summary: Multivitamin Oral Tablet 1 tablet by mouth. R31's (Schedule date: 02/06/2024 - 02/06/2024)…
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 10 citations
- Potential for harm · D2024-02-08 · 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 observations, interviews and record reviews, the facility failed to check and document the temperature of residents' personal refrigerators daily. This failure affected 2 (R7 and R8) residents reviewed for personal food in the total sample of 30 residents. Findings include: 1.) On 02/05/24 at 10:45 AM, there was a personal refrigerator inside R8's room. There were ice cream bars and concentrated juice inside the refrigerator. R8's personal refrigerator temperature log has missing entries. On 02/05/24 at 10:55 AM, these observations were pointed out to V3 (Registered Nurse). V3 stated there are 2 ice cream bars and 2 concentrated apple juice in (R8)'s refrigerator. I (V3) don't know who checks the temperature of the resident's personal refrigerator. Looking at (R8) temperature log, V3 stated there is a lot of temperatures missing for January. On 02/07/2024 at 1:19pm, V2 (Director of Nursing) stated the 3-11 pm shift CNA is supposed to check the temperature of the resident's refrigerator. The importance of checking the refrigerator temperature is to make sure residents have…
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 before2023-01-06 · 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 policy on food storage to ensure food items in the coolers were discarded within the recommended dates after the best by dates, to maintain freshness and prevention of apparent signs of spoilage for fruits and vegetables, and to date food items after being opened. These failures have the potential to affect all 41 residents residing in the facility who are receiving oral diets. Findings include: On 1/03/23 at approximately 9:36 AM, an initial kitchen tour was conducted with V5 (Dietary Manager). The following were observed: Cooler 4 with a temperature of 39 degrees Fahrenheit (F): An opened pineapple juice bottle with no label when it was opened. An opened half and half creamer with no label when it was opened. A container of large curd cottage cheese with best by date of 12/19/22. V5 stated that food items should be dated after opening. V5 also stated that facility does not discard food items on the best by dates. V5 stated, We go by days beyond the best by because it's what's recommended.…
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 before2023-01-06 · tag F0578 — failed to honor advance directives / code status — patternHonor 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 interview and record review the facility failed to obtain a Physician order and update the resident record with the correct code status for 4 of 4 (R7, R12, R33, R42) residents in a sample of 13. Findings include: 1. R7 was admitted to the facility on [DATE] with diagnoses not limited to Atrial Fibrillation, Major Depressive Disorder, Spinal Stenosis, Rheumatoid Arthritis, Hypothyroidism, Mild Cognitive Impairment, Essential (Primary) Hypertension, Venous Insufficiency and Rhabdomyolysis. R7's MDS (Minimum Data Set) Section C Cognitive Pattern BIMS (Brief Interview for Mental Status) score of 15 indicates intact cognition. Order Summary Report dated [DATE] has no documented Physician order for a Code Status. Order Summary Report dated [DATE] Order Status: Discontinued document in part: DNR (Do Not Resuscitate) order date [DATE] order discontinued [DATE], DNR order date [DATE] order discontinued [DATE], DNR order date [DATE] order discontinued [DATE] and DNR order date [DATE] order discontinued [DATE].…
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 · E2023-01-06 · tag F0678 — failed to provide CPR when needed — patternProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
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 a.) ensure staff obtained a physician order for the code status for 5 (R7, R12, R33, R37, R42) residents, and b.) ensure staff knew how to confirm the residents' code status in an emergency. Findings include: On [DATE] at 10:35 AM during the review of R7's Advance Directives it was noted that there was no Physician order for a code status or code status documented on R7's Face Sheet. POLST (Physician Orders for Life Sustaining Treatment) Form dated [DATE] documents in part: Do Not Attempt Resuscitation/DNR. Limited additional interventions. Only use medical treatment antibiotics, IV (Intravenous) Fluids and cardiac monitor as indicated. Treatment Plan: Provide Basic Medical Treatments. Review of health records read as follows: R7 was admitted to the facility on [DATE], Order Summary Report dated [DATE] has no documented Physician order for a Code Status. Order Summary Report dated [DATE] Order Status: Discontinued documents in part: DNR (Do Not…
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 before2023-01-06 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to (a) properly discard multi-dose inhaler 30 days of opening for 1 resident (R27); and (b) properly store medications in the refrigerator separate from food items and supplement drinks that can potentially affect 18 residents (R37, R42, R10, R39, R19, R22, R32, R9, R24, R18, R30, R35, R40, R27, R7, R38, R4, R11) inspected for medication storage and labeling. Findings include: On 01/03/23 at 12:34 PM 2nd floor medication cart was inspected with V11 (Registered Nurse/RN) and found R27's Advair multi-dose inhaler was observed to had been opened on 12/3/22 with an expiration date of 1/2/23. This medication was still in medication cart (1/3/23). V11 stated that the Advair inhaler was already ordered from the pharmacy and awaiting delivery. At 12:40 PM 2nd floor medication room inspected with V11 (RN). A white refrigerator was observed with the following items: applesauce, chocolate pudding, supplemental dietary drinks, juices (cranberry, apple, orange), 2 bottles of beer (V11 stated those are for residents). 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 · D2023-01-06 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to follow its abuse policy by not providing necessary care inservices, resulting in a female resident physically assaulting another male resident for two (R3 and R29) out of four residents reviewed for physical abuse. Findings include: On 01/03/23 at 01:35 PM, surveyor observed R29 in R29's room. R29 stated he (R29) was kicked and punched by R3. R29 stated that R3 resides down the hall. R29 stated, Multiple times she (R3) hits me (R29). On 01/03/23 at 01:40 PM, V1 (Administrator) stated that she (V1) is aware of the abuse altercation between R3 and R29. She (V1) stated R3 hit R29 first. On 01/05/23 at 10:00 AM, V2 (Director of Nursing) stated that she (V2) is aware of the abuse from R3 hitting R29 first. V2 stated, This is not the first time this has happened. R3's care plan is not updated. We told the family but no interventions were put in place or at least it is not documented. On 01/05/2023 at 10:00 AM, V3 (Director of Social Services) stated V3 was standing by the reception desk on the day of the incident and heard a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-01-06 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, failed to follow their Abuse policy by failing to report to Illinois Department of Public Health an incident between two residents (R3 and R29) in a sample of 4 residents reviewed for abuse. Findings include: On 01/03/23 at 01:35 PM, surveyor observed R29 residing in R29's room. R29 stated he (R29) was kicked and punched by R3. R29 stated that R3 resides down the hall. R29 stated, Multiple times she (R3) hits me (R29). On 01/03/23 at 01:40 PM, V1 (Administrator) stated that she (V1) is aware of the abuse altercation between R3 and R29. She (V1) stated R3 hit R29 first. She (V1) stated that she (V1) did not report the abuse incident to Illinois Department of Public Health. On 01/05/2023 at 10:00 AM, V3 (Director of Social Services) stated on the date of the incident, V3 was standing by the reception desk and heard a loud commotion. V3 stated, R29 stated 'She (R3) hit me (R29) and I (R29) hit her (R3) back.' The abuse was witnessed by the CNAs. R3 hit R29 first on 12/2/2022. This is not the first time this incident occurred. The first incident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-01-06 · 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 interview and record review the facility failed to ensure a comprehensive care plan was in place for the Advance Directives for 3 (R39, R40, R42) of 3 residents reviewed for code status in a sample of 13. Findings include: On 01/05/23 during the record review of Advance directives it was noted by the surveyor that (R39, R40, R42) had no documented care plan for Advance Directives or code status. R39 was admitted to the facility on [DATE]. On 01/05/23 during review of R39 there was no Advance Directive Care Plan. R39's POLST (Physician Orders for Life Sustaining Treatment) Form dated 09/14/22 documents in part: Do Not Attempt Resuscitation/DNR. Selective Treatment. R40 was admitted to the facility on [DATE]. On 01/05/23 during review of R40 there was no Advance Directive Care Plan. R39's POLST (Physician Orders for Life Sustaining Treatment) Form dated 11/06/20 documents in part: Do Not Attempt Resuscitation/DNR. Selective Treatment. R42 was admitted to the facility on [DATE]. On 01/05/23 during 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 · D2023-01-06 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
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 assistive device to maintain hearing abilities for 1 (R5) of 1 resident who has hearing impairment in a sample of 13 residents reviewed for hearing. Findings include: On 1/03/23 at 11:09 AM, R5 was sitting on a wheelchair alert and verbally responsive. Surveyor attempted to interview R5. R5 stated, What? What are you saying? I can't hear you. Surveyor observed R5 with no hearing aids or any type of assistive device for hearing. On 1/03/23 at 11:10 AM, during interview V6 (Certified Nursing Assistant/CNA) stated that V6 is in charge of R5. V6 stated R5 is still able to verbalize needs but is very hard of hearing. V6 stated R5 has no hearing aids. V6 stated, R5 has no hearing aids. I haven't seen (R5) with hearing aids. Sometimes (R5) doesn't understand when I talk so I use hand gestures. On 1/03/23 at 11:22 AM during interview V7 (Licensed Practical Nurse) stated that R5 is hard of hearing and should have hearing aids to communicate. V7 stated, R5 should have 2 hearing aids. She's (R5) had them for a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-06 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
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 medication error rate less than 5% for 3 of 9 residents (R10, R38, R18) in the sample reviewed. There were 25 opportunities and 3 errors resulting in a 12% medication error rate. Findings include: On 01/03/23 at 11:57 AM Medication pass observation was conducted with V11 (Registered Nurse). V11 was observed preparing Humalog KwikPen Solution Pen-injector for R10. V11 was observed immediately setting the dose dial to 15 units as ordered without priming the insulin pen. V11 was observed injecting the Humalog insulin pen to R10's right lower side of abdomen. On 01/03/23 at 12:28 PM V11 was observed preparing Ventolin HFA inhaler for R38. V11 was observed giving instructions to R38 and administered the first puff of Ventolin inhaler. V11 shook the inhaler for about 3 to 5 seconds and administered the 2nd puff of Ventolin inhaler to R38 without waiting for at least 1 minute between puffs. On 01/03/23 at 12:50 PM V11 was observed preparing Ventolin HFA inhaler for R18. V11 was observed giving instructions 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.
“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
$9,272 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $9,272 — penalty dated 2025-03-07
- Medicare payment denial — starting 2025-05-27 for 5 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to LITTLE SISTERS OF THE POOR — 4 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 | 5 of 5 | 5.0 | ≈ chain avg |
| Health inspection | 4 of 5 | 4.3 | -0.3 vs chain |
| Staffing | 5 of 5 | 4.7 | +0.3 vs chain |
| Quality measures | 5 of 5 | 3.5 | +1.5 vs chain |
The other 3 homes this chain runs (chain average 5.0★, per CMS)
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 |
|---|---|---|---|---|
| MCCANLESS, CLAIRE | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | 50% | since 01/01/2017 |
| DONNELLY, ANN | Individual | CORPORATE OFFICER | — | since 06/01/2017 |
| MARTIN, CAROLYN | Individual | CORPORATE OFFICER | — | since 06/01/2017 |
CMS files one row per role, so the 5 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.
What families pay in IL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 146185. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-07, 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.