Mado Healthcare - Uptown
4621 North Racine Avenue, Chicago, IL 60640 · For profit - Corporation · 132 certified beds · (773) 784-2300 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- lower-than-typical staff turnover (30% vs 45% nationally) — better care continuity
- it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Jun 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $123,614 in federal fines (most recent 2024-11-20)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 1 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 | 1 of 5 |
| Long-stay residentspeople who live here | 1 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 1 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 | 8.2% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.5% | 6.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.4% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 98.4% | 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 | 1.3% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 5.7% | 14.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 4.6% | 18.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 99.2% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.9% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 10.9% | 20.6% | 21.2% | better |
| Short-stay residents rehospitalized after admission | 31.2% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 7.2% | 13.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.88 | 2.02 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.88 | 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.
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 0.10 therapist hours per resident per day in 2025Q4 — more than 7% of the 13,714 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.5%CMS range 5.8–14.7 | 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 | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 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 | 6.5%CMS range 3.3–12.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.92 | 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 132 beds and averages 112.2 residents a day — about 85% occupied, or roughly 20 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.87 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.54 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.69 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 2.50 hrs/resident/day on weekends vs 2.91 on weekdays — 14% thinner on weekends. RN hours go from 0.58 to 0.47 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 30% is below the national median of 45%. 3 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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.
33 citations, most serious first. The 12 most serious are shown; the remaining 21 are one tap away and print in full.
- Immediate jeopardy · J2024-09-23 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
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 establish a system of accounting for resident's funds and safeguarding resident's funds against theft, failed to follow their system of updating resident's belongings, and failed to ensure shipping address of online purchase for the resident was to the facility. These failures resulted on R1 and R6 incurring fraudulent debit card transactions on R1's and R6's bank accounts. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy was identified on 03/25/2024 when V14 (R1's family member) completed a concern form regarding unexplained activities on R1's bank account. On 09/16/2024 at 10:45am, V1 was notified of the Immediate Jeopardy. This surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 09/23/2024. Although the immediacy was removed, the deficiency remains at a level 2 until the facility can determine the effectiveness of the implementation of removal and effectiveness of 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.
- Actual harm · Gcited before2025-01-03 · 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 review of records and interview, the facility failures are the following: Failed to follow interventions in the care plan, review and/or revised the fall prevention care plan of 1 out of 4 residents (R1) reviewed for accidents and hazards. Failures affected 1 resident (R1) who had an incident of fall resulting to right hip/pelvic fracture that required surgery in the hospital. Finding includes: R1 is [AGE] years old, a resident in the facility since 10/08/2020. R1 has moderate impairment of cognition based on brief interview of mental status (BIMS) dated 10/15/2024, with a score of 12. R1 was not in the facility during review, per V10 (Registered Nurse) nursing notes dated 12/28/2024. R1 was transferred to the hospital due to vomiting. On 12/31/2024, at 11:21 AM. V8 (Licensed Practical Nurse) stated that R1 used to be in the current floor that she is working. R1 was admitted on a different floor after hospitalization. V8 stated that R1 underwent hip surgery. R1 was ambulating without any help before 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 · F2025-12-12 · tag F0636 — widespreadAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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 complete timely comprehensive smoking assessment for 8 (R6, R8, R9, R21, R39, R79, R89, R110) residents reviewed for smoking. This failure affected ALL 59 smoker residents in the facility. The findings include: R9's admission record showed admit date on 8/5/2025 with diagnoses not limited to Malignant neoplasm of unspecified part of left bronchus or lung, Chronic obstructive pulmonary disease, Type 2 diabetes mellitus, Anemia, Schizoaffective disorder, Emphysema, Unilateral primary osteoarthritis left knee, Peripheral vascular disease. MDS (Minimum Data Set) dated 11/11/2025 showed R9's cognition was intact. R110's admission record showed admit date on 7/14/2022 with diagnoses not limited to Type 2 diabetes mellitus, Unspecified dementia, Chronic obstructive pulmonary disease, Unspecified asthma, Epilepsy, Chronic kidney disease, Essential (primary) hypertension, Chronic ischemic heart disease, Schizophrenia. MDS dated [DATE] showed…
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 before2025-12-12 · 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 a.) ensure food items were properly labeled and dated, b.) store food at least six inches from the floor, c.) store food at least 18 inches from the ceiling, d.) sanitize kitchen equipment based on manufacturers' procedure directions. These failures have the potential to affect all 112 residents receiving food prepared in the facility's kitchen. Findings include: On 12/09/25 at 9:29 AM, V5 (Dietary Manager) stated all prepared or opened food containers are labeled with a prepared or opened date and a use by date or expiration date. V5 stated it is important for the items to be labeled and dated with an open and use by date, so the staff knows how long the product is good for. V5 stated if the product is only labeled with an opened date the staff may not know when the item should be thrown out and they may continue to use the product even though it has expired. V5 stated if an item is not dated appropriately then they throw it out and do not serve to the residents because there is a potential for 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 · Fcited before2025-12-12 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to clean and disinfect reusable equipment (glucometer) in between resident's use and ensure staff performed hand hygiene in between resident's care during medication administration. The facility also failed to maintain their hot water temperatures within required parameters and failed to develop and implement a comprehensive water management plan to prevent and control the growth of Legionella and failed to establish control measures for areas at risk for Legionella growth within the facility's water system. These deficient practices have the potential to promote the growth and spread of Legionella in the facility water system and could affect all 112 residents residing in the facility. Findings Include: On 12/09/25 at 12:55 PM, surveyor requested from V1 (Administrator) their water management program for Legionella. V1 stated that the facility has no completed water management program and is working on completing one. V1 said that they started putting it together a year ago, but it's not complete yet. V1 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 · Ecited before2025-12-12 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
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 ensure a medication error rate was less than 5% for 5 (R28, R29, R46, R103 and R116) of 16 residents reviewed for medication administration. There were 26 opportunities and 5 errors resulting in a 19.23% medication error rate. The findings include: R 1. R46's admission record showed admit date on 6/4/2025 with diagnoses not limited to Other asthma, Essential (primary) hypertension, Type 2 diabetes mellitus, Other schizophrenia, Neuromuscular dysfunction of bladder. MDS (Minimum Data Set) dated 9/9/2025 showed R46's cognition was intact. On 12/9/2025 at 10:01AM Medication administration observation conducted with V4 (Licensed Practical Nurse / LPN) and gave Symbicort inhaler to R46. Observed R46 inhaled 1 puff and in 2 seconds interval inhaled another puff. R46 did not wait for at least 1-2 minutes before the 2nd puff inhalation. 4 R46's POS (Physician Order Sheet) and MAR (Medication Administration Record) showed in part: Symbicort…
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 before2025-12-12 · 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
Based on observations, interviews and record reviews, the facility failed to provide ADL (Activities of Daily Living) care assistance and ensure nail care was provided to one resident (R110) who is unable to carry out ADL independently of two residents reviewed for ADL in a sample of 23. The findings include: R110's admission record showed admit date on 7/14/2022 with diagnoses not limited to Type 2 diabetes mellitus, Unspecified dementia, Chronic obstructive pulmonary disease, Unspecified asthma, Epilepsy, Chronic kidney disease, Essential (primary) hypertension, Chronic ischemic heart disease, Schizophrenia. MDS (Minimum Data Set) dated 9/2/25 showed R110's cognition was moderate impaired. She needed supervision or touching assistance with upper body dressing; Partial / moderate assistance with personal hygiene and body dressing. On 12/9/2025 at 2:35PM Observed R110 sitting up on wheelchair, alert and verbally responsive. Observed clothes (sweater and pants) stained with food, brownish and reddish in color. Observed fingernails on both hands were long and dirty, with blackish…
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 before2025-12-12 · 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 change oxygen nasal cannula and humidifier bottle as ordered for two (R11, R106) residents out of two reviewed for respiratory care in a final sample of 23. Findings Include:On 12/9/25 at 12:01 PM, Surveyor entered R11 and R106's room with V4 (Licensed Practical Nurse). R106 and R11 were not in their rooms and noted oxygen concentrators at R11 and R106's bedside not being used. R11 and R106's oxygen tubing and humidifier bottles were dated 12/1/25. V4 said they should have been changed on 12/7/25. V4 said that R11 and R106 uses oxygen as needed. On 12/10/25 at 12:57 PM, V2 (Director of Nursing) stated any respiratory tubing, and humidifier bottle are supposed to be changed every seven days and as needed. Even if it's an as needed order still needs to be changed. V2 said nurses should label it with the date it was last changed. V2 said changing oxygen tubing and humidifier bottle is important to prevent infection and growth of bacteria and to prevent residents getting sick.R11 and R106's order summary reports…
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 before2025-12-12 · 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, record review the facility failed to properly discard a multi-dose insulin 28 days after opening for one (R86) resident and properly store multidose insulin vials that require refrigeration for one (R16) resident reviewed for medication storage and labeling in three of five medication carts and storage rooms. The findings include: R16's admission record showed initial admit date on 2/5/21 with diagnoses not limited to Type 2 diabetes mellitus, Presence of other cardiac implants and grafts, Unspecified right bundle-branch block, Chronic kidney disease stage 3, Essential (primary) hypertension, Schizoaffective disorder, Unspecified sequelae of cerebral infarction. R86's admission record showed initial admit date on 6/5/2020 with diagnoses not limited to Type 2 diabetes mellitus, Chronic obstructive pulmonary disease, Chronic systolic (congestive) heart failure, Essential (primary) hypertension, Schizoaffective disorder, Other seizures. On 12/9/2025 at 10:33 AM 4th floor medication cart inspected with V12 (RN / Registered Nurse) and observed multidose…
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 · D2025-12-12 · tag F0825 — isolatedProvide or get specialized rehabilitative services as required for a resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow physician order to provide specialized rehabilitation therapy post-fall for one (R102) resident reviewed out of a total sample of 23 residents. Findings include:On 12/11/25 at 12:22 PM, observed R102 sitting in the dining room in a wheelchair waiting for his lunch tray to be delivered. R102 said he used to walk around with a walker before he fell but now, he uses a wheelchair because he hurt his leg when he fell. R102 stated he does not know if he is getting therapy or not. Per R102's EHR (Electronic Health Record) R102 had an unwitnessed fall in his room on 11/10/25 and sprained his right ankle per discharge hospital records dated 11/10/25. Per R102's nursing progress noted R102 went for a follow up appointment with an orthopedic on 11/12/25 with recommendations for weight bearing as tolerated (WBAT) in a gym shoe and PT/OT (Physical Therapy/Occupational Therapy) to work on ROM (Range of Motion) and gait mechanics. Per R102'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 · Dcited before2025-08-21 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide a prescribed treatment to one resident (R3). This failure affected one out of three residents reviewed for treatment services.Finding include:R3's medical diagnoses include but are not limited to chronic obstructive pulmonary disease, localized edema, cellulitis of unspecified part of limb, essential hypertension, heart failure.R3's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 15, indicating R3's cognition is intact.On 08/18/25 at 11:48am R3 observed in first floor dining area with no bandages to bilateral lower legs.On 08/18/25 at 1:51pm R3 stated that the nurses wrap her legs sometimes. R3 stated that she did not get her legs wrapped today on 08/18/25.Review of R3's treatment administration record shows documentation of R3's legs being wrapped with ace bandages.On 08/19/25 at 10:23 am R3 observed in first floor dining are with no bandages to bilateral lower legs.On 08/19/25 at 10:23am…
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 before2025-06-21 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the right of the resident to be free from physical abuse in 1 (R1) of 3 residents reviewed for abuse in a sample of 8. The findings include: R1 is a [AGE] year old male with a diagnosis including COPD, Dementia, Major depressive disorder and History of falling. R1 has a BIMS (Brief Interview for Mental Status) score of 13/15. R1 ambulates independently by wheelchair. R1 is care planned for being a potential risk for Abuse/Neglect. R1 was first admitted to the facility on [DATE]. Facility Incident Report Form dated 6/6/25 includes statement that on 6/4/25 corporate staff were reviewing video recording that shows V3 ( Housekeeper) moves R1's wheelchair unnecessarily and forcefully. R1 places his foot on the ground appearing to be non verbally communicating that he does not want to move. Despite this V3 lifts the front wheels of the wheelchair and moves R1 whose feet are visibly hanging. On 6/20/25 at 10:39AM R1 stated yes I remember…
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 21 citations
- Potential for harm · Dcited before2025-05-04 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their policy by failing to notify the nurse on duty of a resident fall and failed to ensure that a resident was immediately assessed by a nurse after sustaining a fall. This failure effected 1 resident (R1) out of 5 residents reviewed for falls in a total sample of seven residents. Findings include: Facility Final Incident Investigation (dated 04/25/2025) documents in part: The certified nursing assistant stated that in the morning he went to the room of R1 and he was sitting on the floor. He tried to get him up from the floor. Staff denied being physically aggressive towards R1. He denied causing any harm to R1. The facility is unable to substantiate the allegation of physical abuse. There was no ill-intentions or intentional act towards R1. R1 sustained a close fracture of the right shoulder. Staff were in-serviced on 04/22/2025, on appropriate transfer practices. Fall Prevention Policy (undated) documents in part: It is the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-25 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect resident's right to be free from physical abuse. This failure affected one (R1) out of three residents reviewed for abuse. Findings include: On 04/22/25 at 11:30 AM, R1 stated R2 tried to choke him when R1 was in the 1st floor dining room doing activities. R1 stated, R2 came up from behind R1 and grabbed R1 around the neck with R2's arm. R1 stated he was not expecting it, so he was surprised when R2 did that. R1 stated one of the staff got R1 off R2 and R2 was removed from the room. R1 does not remember if R2 said anything as he was trying to choke R1. R1 stated R2 did not look angry and I don't know why he did that. On 04/22/25 at 11:10 AM, observed R2 sitting in his bedroom looking at an opened bible on his bedside table. V21 (Business Office Manager) acted as translator because R2's primary language is Spanish. R2 stated via V21 that God, told me to choke him (R1) so I did and God told me to do this because he (R1) was going to try to choke…
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 · D2025-04-25 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to (a) assess and document pressure ulcer characteristics and measurement on a weekly basis and (b) ensure that the orders provided by wound nurse practitioner (NP) were performed to 1 (R3) out of 3 residents reviewed for Improper nursing care. The findings include: R3's admission record showed initial admission date on 5/19/2021 with diagnoses not limited to Acute respiratory failure with hypoxia, Pressure ulcer of right heel stage 3, Morbid (severe) obesity due to excess calories, Chronic respiratory failure with hypoxia, Pressure ulcer of right buttock stage 2, Unspecified diastolic (congestive) heart failure, Acute embolism and thrombosis of unspecified deep veins of right lower extremity, Unspecified urinary incontinence, Type 2 diabetes mellitus, Schizoaffective disorder, Chronic obstructive pulmonary disease. R3 was discharged from the facility on 4/15/2025. On 4/22/25 at 10:25AM V5 (LPN / Licensed Practical Nurse) stated wound treatment is done by nurse on duty, had regularly worked and provided treatment to R3'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 · F2024-11-20 · tag F0659 — widespreadProvide care by qualified persons according to each resident's written plan of care.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to have a qualified licensed nurse oversee the facility's restorative nursing program. The failure has the potential to affect all 120 residents that receive restorative programming. Findings include: On 11/17/24 at 10:25 AM, V5 (Restorative Director) stated that V5 is the restorative director and that V5 is a COTA (Certified Occupational Therapist Assistant). On 11/18/24 at 9:55 AM, V1 (Administrator) stated that V5 supervises the restorative programming in the facility. On 11/18/24 at 12:22 PM, V5 stated that V5 creates and evaluates all restorative programs in the facility. V5 explained that V5 is responsible for assessing residents for restorative need and creating a restorative care plan. V5 stated that all restorative certified nursing assistant aides report to and are supervised by V5 and V5 completes all the training on restorative for staff members. V5 stated that V5 was qualified to supervise the restorative nursing program because V5 had taken a course on restorative nursing. On 11/19/24 at 10:09 AM, V2 (Director…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-11-20 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure window blinds are not missing blind panels/slats in an effort to provide a homelike environment to residents. This failure affected 5 (R53, R74, R76, R82, R91) residents reviewed for homelike environment in the total sample of 57 residents. Findings include: On 11/17/2024 at 10:27 AM, inside R82's room, the vertical window blinds have missing panels/slats. There were no panels/slats on the floor. On 11/17/2024 at 10:29 AM, inside R91's room, the vertical window blinds have missing panels/slats. There were no panels/slats on the floor. On 11/17/2024 at 10:35 AM, V12 (Certified Nursing Assistant) was requested to check R82's window blinds. V12 stated the window blinds should have more coverage to provide privacy; there were missing panels (slats). I don't know how long it has been like that. No, I don't see any window blind panels (slats) on the floor. On 11/17/2024 at 10:38 AM, V12 (Certified Nursing Assistant) checked R91's window…
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 before2024-11-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide 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 interview and record review, the facility failed to ensure oxygen signs were placed on the resident's door and failed to properly label and date oxygen tubing. This failure affects 3 residents (R86, R93, R25) and has the potential to affect all 25 residents that reside on the 5th floor. Findings include: On 11/17/24 at 10:47 AM, R25 was observed lying in bed with nasal cannula in R25's nostrils. R25 had an oxygen concentrator on next to R25's bed, delivering oxygen to R25. No oxygen in use signage was observed on the resident's door or in any place of high visibility on the unit. On 11/17/24 at 10:52 AM, V10 (Agency Licensed Practical Nurse) affirmed that there was no sign on R25's door. V10 stated that V10 was unsure if there is supposed to be oxygen signage on the door to alert others to R25's oxygen use. V10 stated that oxygen is flammable and can combust if exposed to flames. On 11/19/24 at 10:27 AM, V1 (Administrator) stated when residents are undergoing oxygen therapy, the facility standard is that the resident should have a sign on their door stating that oxygen is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-11-20 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure that the controlled drugs-count record form was not prematurely signed by in and outgoing nurses. These failures have the potential to affect all residents on the second, fourth, fifth, and six floors receiving medications. Findings Include: On 11/17/24 at 12:40 pm, on the second floor the controlled drugs- count record sheet was prematurely signed for the outgoing nurse. On 11/17/24 at 12:41 pm, surveyor inquired to V9 LPN (License Practical Nurse) why is the controlled drugs- count sheet prematurely sign for the outgoing nurse? V9 stated, I always sign for outgoing when I sign for incoming because there are no medications in there. Surveyor inquired to V9 if it is checked with the incoming nurse at the beginning and ending of each shift. V9 stated, that's how I do it, I sign both when I come in because nothing is in there. On 11/17/24 at 1:45 pm, surveyor requested the controlled drug-count records for all resident floors. V2 DON (Director of Nursing) gave the third, fourth, fifth and six floor'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 · Dcited before2024-11-20 · 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 record review the facility failed to discard an expired medication. This failure has a potential to affect one resident (R74) in a sample size of 57 residents. Findings Include: On 11/17/24 at 12:20 pm, the third-floor medication cart had R74's Breo Ellipta (Fluticasone Furoate-Vilanterol Inhalation Aerosol Powder Breath) that was labeled to use by 11/14/24. R74's admission diagnosis includes but not limited to asthma, COPD (Chronic Obstructive Pulmonary Disease), and congestive heart failure. R74's active orders as of 11/18/24 documents in part, Fluticasone Furoate-Vilanterol Inhalation Aerosol Powder Breath Activated 200-25 MCG/ACT 1 puff inhale orally one time a day for Antiasthma. R74's MAR (Medication Administration Record) documented in part, (Fluticasone Furoate-Vilanterol Inhalation Aerosol Powder Breath) had a check mark indicating administered on 11/15/24, 11/16/24 and 11/17/24. On 11/17/24 at 12:21 pm, V15 RN (Registered Nurse) stated, I cleaned the cart and missed that. Observed V15 take the inhaler out of the medication cart. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-20 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure an Enhanced Barrier precaution (EBP) sign is posted for a resident on EBP and failed to ensure a PPE (personal protective equipment) bin is available for resident on EBP. These failures affected 1 (R76) resident reviewed for infection control. Findings include: On 11/17/2024 at 10:25 AM on 3rd floor, there was an EBP sign posted by the door with R76's room identifier. A PPE bin was also available outside of the room with R76's room identifier. The room was located at the end of the hallway. This surveyor knocked on the door. No one was in the room. On 11/17/2024 at 10:46 AM, R76 was in a room located right across the 3rd floor's nurse's station in the middle of the hallway. The room identifier did not indicate R76 was residing in that room. There was no EBP sign nor PPE bin on site. ON 11/17/2024 at 11:36 am, on the end hallway on 3rd floor with V15 (Agency Registered Nurse) this surveyor pointed to the EBP sign posted on the door and the PPE bin outside of the room and inquired who was the resident on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-20 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
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 provide functioning call device for residents requiring assistance from staff. This failure affected 2 (R91, R98) residents reviewed for resident call system in the total sample of 57 residents. Findings include: On 11/17/2024 at 10:40 AM, V12 (Certified Nursing Assistant) checked R91's call device and stated the call light is broken; the call light box is not lit to indicate it is working. On 11/17/2024 at 10:49 AM, V12 checked R98's call device and stated the call light box is not lit to indicate it is working. ON 11/17/2024 between 10:52am and 11:05am, V13 (Maintenance Supervisor) checked R91's and R98's call devices and corroborated the observations done by this surveyor with V12. On 11/17/2024 at 11:09 AM, V13 stated it is expected to have a properly functioning call light to let the nursing staff know the resident needs assistance. How can they ask for assistance if the call light is broken. On 11/18/2024 at 11:23am, V2 (Director of Nursing) stated we should provide a functioning call device to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-09-23 · tag F0607 — failed to have anti-abuse policies — widespreadDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
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 their own policy to conduct a complete background check of employees prior to working with residents. This failure has the potential to affect all the residents at the facility. Findings include: The (Effective as of 08/29/2024) untitled document indicated that V5 (PRSC) was hired on 07/31/2023, V7 (CNA Supervisor) was hired on 04/01/2024, V8 (Certified Nursing Assistant) was hired on 06/27/2024, V9 (CNA) was hired on 08/01/2024, V10 (CNA) was hired on 04/30/2024, and V11 (PRSC) was hired on 03/31/2024. The (09/06/2024) email correspondence with V1 (Administrator) documented that V5 works on the 3rd floor, V7 works on all the floors, V8 works on any floor, V9 works on the 2nd and 3rd floor, V10 works on the 3rd floor, and V11 works on the 4th floor. On 09/04/2024 at 10:33am, V4 (Office Manager/HR Director) stated the purpose of the healthcare worker background check is to see if staff are eligible to work in a nursing home facility. To make sure the correct kind of people with good character are working here at 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 · F2023-12-07 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure the Daily Nurse Staffing was conspicuously posted in a prominent place readily accessible to residents and visitors. This failure has the potential to affect all 120 residents residing in the facility. Findings include: On 12/04/2023, V1 (Administrator) presented a facility census of 120 residents. On 12/04/2023 at 9:10 am, surveyors enter the facility and did not observe the Daily Nurse Staffing that included the facility name, date, residents census and hours worked per shift for licensed and unlicensed staff responsible for resident care posted visibly in a prominent place in the facility. On 12/04/23 at 1:08 pm, Surveyor requested V1 (Administrator) to locate the daily staff posting for the facility and V1 stated, We (referring to the facility) don't have one. When V1 was asked the importance of the Daily Staff Posting for the facility V1 stated So everyone knows how many staff are in the building. V1 explained that a schedule is kept at the receptionist desk however there is no posting for visitors…
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 before2023-12-07 · 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 store, prepare, distribute and serve food in accordance with professional standards for food service safety. These failures have the potential to affect all residents who consume food prepared by the facility. Findings include: On 12/04/23 at 10:06 AM, the food service area toured. Floor of food service area has ceramic floor tiles missing and cracked in front of the dishwasher and steam table. Grout between tiles throughout food service area are heavily soiled from black encrustation and not easily cleanable. The entrance/interior of walk in cooler has ceramic tiles missing and cracked on the floor. The floor is not easily cleanable. On 12/04/23 at 10:10 AM, The dietary hand sink located next to coffee machine has cleaned silverware under coffee machine on shelf. The silverware and coffee machine are subject to splash from the handwashing sink when in use. Staff were observed using the handwashing sink during this observation. On 12/4/23 at 10:08 AM, the dry food storage room was observed with two plastic bulk…
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 · D2023-12-07 · 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 observation, interview and record review the facility failed to ensure the call light device was within reach for one resident (R19). This failure has the potential to affect one resident (R19) out of a sample of 44. Findings include: R19 has a diagnosis of but not limited to Epilepsy, Schizophrenia, Alzheimer's Disease, and Pure Hypercholesterolemia. R19 has a Brief Interview of Mental Status score of 00. Care plan focus: ADL's related to medical and psychiatric condition (4/21/2022) documents in interventions to keep call light within reach and instruct the resident in the proper use of the call light. Call light assessment had not been completed for R19. On 12/04/23 at 10:57 am, surveyor observed R19 in the bed with call light device on the floor behind the night stand and not within reach of the resident. R19 stated Don't know when asked where her call light was. On 12/04/2023 at 10:59 am, V20 (CNA) stated R19's call light was on her bed, as he was looking for the call light, and then said he does not see R19's call light. On 12/04/2023 at 11:01 am, V21 (LPN) 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 before2023-12-07 · 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
Based on observation, interview and record review the facility failed provide ADL (Activities of Daily Living) to one resident (R28) reviewed for ADL's in the sample of 44. Findings include: R28 has a diagnosis of but not limited to Pneumonia, Moderate Protein-Calorie Malnutrition, Epilepsy, Schizoaffective Disorder, Allergic Contact Dermatitis and Chronic Obstructive Pulmonary Disease. R28 has a Brief Interview for Mental Status score of 11. On 12/4/2023 at 11:17 am, surveyor observed R28's fingernails to be long on both hands. R28 stated that his nails are too long for a man and would like them to be trimmed. On 12/5/2023 at 2:42 pm, surveyor observed R28's fingernails to be long on both hands. On 12/05/2023 at 2:46 pm, V16 (CNA) stated resident's fingernails are trimmed every time she notices that they are dirty and or long and nail care is provided with showers. On 12/06/2023 at 12:34 pm, V1 (Administrator) stated staff are expected to provide nail care when providing ADL care, during showers and as needed. Activities of Daily Living Policy dated 1/4/2023 documents, in part, 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 before2023-12-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review the facility failed to provide supervision while shaving for one resident (R5), reviewed in a sample of 44. Findings include: R5 is [AGE] year old with diagnosis including but not limited to: Schizoaffective Disorder, Schizophrenia, Chronic Obstructive Pulmonary Disease, Age-related Osteoporosis and Cataract Extraction. On 12/5/23 at 10:04 AM, R5 was observed in bathroom located in day room on the fifth floor. The bathroom door was cracked and Surveyor observed R5 inside of the bathroom shaving with a manual cartridge razor. No staff members were observed in or near the bathroom with R5. On 12/5/23 at 10:10 AM, Surveyor observed V10 (Certified Nurse Assistant /CNA) enter the bathroom with R5 to retrieve the razor. On 12/06/2023 V1, (Administrator) said, The residents cannot shave themselves. We (staff) have to shave them (residents) or stand near and supervise them while they are shaving for safety reasons. There are no orders for shaving. Everyone has 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 before2023-12-07 · 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 administration error rate of less than 5 percent for 2 of 7 residents (R119, R3) reviewed for medication administration. There were 33 opportunities and 3 errors resulting in a 9.09% medication administration error rate. Findings include: R3's diagnosis includes but are not limited to chronic obstructive pulmonary disease, unspecified, difficulty in walking, not elsewhere classified, unsteadiness on feet, other abnormalities of gait and mobility, abnormal posture, unspecified lack of coordination, hyperlipidemia, unspecified, anemia, unspecified, bipolar disorder, unspecified, pure hypercholesterolemia, unspecified, essential (primary) hypertension, history of falling, vitamin deficiency, unspecified, osteoarthritis of hip, unspecified , unspecified asthma, uncomplicated, schizophrenia, unspecified, muscle weakness (generalized), and altered mental status, unspecified. R3's Brief Interview for Mental Status (BIMS) dated 10/31/2023 documents R3 has a BIMS score of 13 which indicates R3'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 · Dcited before2023-12-07 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review the facility failed to ensure that expired eye medication was removed from the medication cart for one resident (R54) from a sample of 44. Findings include: R54 is [AGE] year old with diagnosis including but not limited to: Primary Open- Angle Glaucoma, Chronic Obstructive Pulmonary Disease, Hyperlipidemia, and Schizoaffective Disorder. On [DATE] during investigation, Surveyor observed an expired eye medication on the third floor medication cart. The expired eye medication was Latanoprost .005% and was labeled with R54's name. The Latanoprost medication had a sticker on the bottle that documented, use by [DATE]. On [DATE] at 10:50 AM, V12 (Licensed Practical Nurse/ LPN) said, The medication (eye drops) expired on [DATE]. I (V12) will discard this and reorder a new one. Surveyor inquired about the possible outcomes of a resident using expired eye medication. On [DATE] at 10:50 AM, V12 (LPN) said, The expired medication may cause adverse (unfavorable) effects for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-07 · tag F0914 — isolatedProvide bedrooms that don't allow residents to see each other when privacy is 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 ensure three residents had a privacy curtain which extended around the bed. This failure affected three residents (R110, R421, R4) (residing in the same room) in a sample of 44 residents. Findings include: R110's diagnosis includes but are not limited to other drug induced secondary parkinsonism, supraventricular tachycardia, unspecified, extrapyramidal and movement disorder, unspecified, gastro-esophageal reflux disease without esophagitis, vitamin D deficiency, unspecified, schizoaffective disorder, unspecified, disorder of teeth and supporting structures, unspecified, acquired absence of left great toe, acquired absence of other left toe(s), bipolar disorder, unspecified, essential (primary) hypertension, cognitive communication deficit, other lack of coordination, history of falling, thrombocytopenia, unspecified. R110's Brief Interview for Mental Status (BIMS) dated 11/06/2023 documents R110 has a BIMS score of 12 which indicates R110 has some moderate cognitive impairment. R4's diagnosis includes but…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement their fall protocol by failing to re-assess a resident after a fall and failed to implement care plan interventions for one (R1) of three residents reviewed for falls. Findings include: R1's medical record (Face Sheet) documents R1 is a [AGE] year-old female admitted to the facility on 5.25.2022 with diagnoses including but not limited to: Epilepsy, Bipolar Disorder, Paranoid Schizophrenia, Lack of Coordination, and Difficulty in Walking. R1's MDS (Minimum Data Set of 7-7-2023) documents R1 is moderately cognitively impaired and experiences hallucinations and exhibits delusions. On 9-30-2023 at 12:05 PM, R1 was observed awake and alert sitting on the side of her bed eating lunch. A soft helmet was noted on R1's head; a CAM (controlled ankle movement) boot was noted on R1's left lower extremity. There were no floor mats noted on the floor in front of resident's bed. On 9-30-2023 at 3:55 PM, V8 (Restorative Supervisor) said, fall…
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 · D2023-10-02 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to maintain accurately documented medical records for one (R1) of three residents reviewed for documentation of medical records. Findings include: On 10-2-2023 at 11:39 AM, via return phone call by V19 (Agency LPN-Licensed Practical Nurse) to Surveyor, V19 said, I wasn't there when R1 had a seizure. PT (Physical Therapy) and CNA (Certified Nursing Assistant) said there was something off about R1. That's when they said she may have had a seizure and fell. I assessed her; there was a difference in size between her ankles, the left ankle was swollen, larger than the right. The seizure happened somewhere before my shift started on the midnight shift. She wasn't experiencing excruciating pain, there was no obvious deformity to extremity noted. I tried to look back on 24-hour report, I didn't see anything in the communication book about a seizure. The off-going nurse never reported to me that R1 had a seizure on the midnight shift. V20 (Agency LPN-Licensed Practical Nurse) was not available for interview (overseas per…
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
$123,614 in federal fines across 2 penalties.
- $8,978 — penalty dated 2024-11-20
- $114,636 — penalty dated 2024-09-23
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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| BRIDGET STUMPF GIFT DESCENDANTS TRUST | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 16% | since 11/20/2013 |
| CAITLIN O'BRIEN GIFT DESCENDANTS TRUST | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 6% | since 11/27/2013 |
| CHARLES F STUMPF, JR. GIFT DESCENDANTS TRUST | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 16% | since 11/20/2013 |
| MEGHAN O'BRIEN GIFT DESCENDANTS TRUST | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 6% | since 11/27/2013 |
| PETER J O'BRIEN, SR GIFT DESCENDANTS TRUST | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 37% | since 11/23/2013 |
| REENIE O'BRIEN GIFT DESCENDANTS TRUST | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 6% | since 11/27/2013 |
| O'BRIEN, PETER | Individual | INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; ADP OF THE SNF | — | since 04/01/1991 |
| GULLY, JACQUELINE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/15/2025 |
| SHAH, BHARAT | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/05/2003 |
| VILORIA, RENITH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/12/2020 |
CMS files one row per role, so the 18 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.5M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 146191. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-12, 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.