Mercy Circle
3659 West 99th Street, Chicago, IL 60655 · Non profit - Church related · 23 certified beds · (773) 253-3600 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (33% vs 45% nationally) — better care continuity
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (15) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 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 |
| Short-stay residentsrehab / post-hospital | 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 with a catheter left in their bladder | 0.0% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 3.6% | 54.2% | 6.5% | better 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 | 3.3% | 3.1% | 3.3% | typical |
| Long-stay residents with pressure ulcers | 1.9% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 17.7% | 20.6% | 21.2% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.1% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 91.5% | 63.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 17.4% | 26.1% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 7.2% | 13.9% | 12.0% | 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.
72.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 182 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 68.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 83 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.87 therapist hours per resident per day in 2026Q1 — more than 95% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 33% 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 | 72.6%CMS range 66.0–77.9 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.0%CMS range 7.5–14.3 | 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 | 68.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 57.8% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 72.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 4.0% | 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 | 2.0% | 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 | 5.7%CMS range 3.3–10.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.16 | 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 23 beds and averages 22.5 residents a day — about 98% occupied, or roughly 0 beds typically open. It runs essentially full — expect a waiting list. 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 4.35 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.41 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.71 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 4.06 hrs/resident/day on weekends vs 4.46 on weekdays — 9% thinner on weekends. RN hours go from 1.63 to 0.87 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 33% 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.
15 citations, most serious first. The 10 most serious are shown; the remaining 5 are one tap away and print in full.
- Potential for harm · F2026-04-30 · 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, interviews and record review, facility failed to follow their policy and federal regulation and failed to ensure that the Daily Nursing Staffing Posting was completed appropriately. These failures have the potential to affect all 23 residents residing at the facility.Findings include:On 4/27/2026 at 9:45 AM, facility presented a census of 23 residents living at the 3rd floor unit.On 4/28/2026 at 12:12 PM, on the 3rd floor unit, observed Daily Nursing Staffing Posting displayed in the hallway by the first nursing station in the glass covered posting cabinet. Observed the Daily Nursing Staffing Posting sheet prefilled with dates from 4/26/2026-5/2/2026, with Facility's name, Nurses and Certified Nursing Assistants (CNA's) total hours per shift, and observed slots for the facility's Census empty, not filled out with the Census information for all the dates on the sheet.On 4/28/2026 at 12:53 PM, V8 (Clinical Services Manager/Assistant of Director of Nursing/ADON) stated that V8 performs scheduling for nursing staff and gives Daily Nurse Staffing Posting information…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2026-04-30 · tag F0761 — failed to label and store drugs safely — widespreadEnsure 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 ensure that the medication carts were kept clean and free of loose pills, failed to ensure multi-use medications were labeled with an open date, failed to discard expired medications and failed to discard expired medication supplies. These failures have the potential to affect all 23 residents assigned to the medication cart.Findings include:On 04/28/26 at 12:38pm during medication storage and labeling task with V4 (Registered Nurse/RN) of 3rd floor medication cart, there were 12 loose unidentified pills observed in the medication drawers, an opened tube of Diclofenac sodium topical gel 1% with no open date, an open tube if bacitracin zinc antibiotic ointment with no open date, Vitamin B1 100mg (milligram) with expiration date of 02/2026, Omeprazole 20mg with expiration date that was unable to be read, tuberculosis needle with expiration date of 01/31/25.On 04/28/26 at 12:38pm V4 (RN) stated that the loose pills on the medication cart should be discarded. V4 stated that the loose pills are trash because they…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2026-04-30 · 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 review, facility failed to follow their policy and federal regulation; failed to ensure that food safety is maintained during lunch serving from a steam table by staff touching ready to eat food with bare hands, wearing only one glove and not washing hands before glove applying or after glove removal; failed to follow proper sanitation practices to ensure that the dishwasher machine sanitized dishes at the proper temperature; and failed to properly contain and label open food in the freezer. These failures affected one resident (R22) and have the potential to cause foodborne illnesses for all 23 residents receiving oral nourishment in the facility.Findings include: On 4/27/26 at 9:15 am, kitchen tour was conducted with V7 Director of Dining Services, and the following findings were observed. At 9:25 am, Walk in freezer observed crab cakes in a silver tray with saranwrap not fully covering the crab cakes and the crab cakes were not dated. V7 Director of Dining Services stated, The crab cakes have been in the freezer since Friday, and they…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-30 · 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 label and date nebulizer mask for one resident (R34). These failures affected one resident (R34) reviewed for respiratory equipment in total sample of 21 residents.Findings include:On 4/27/26 at 11:00 am, R34 was observed in bed with a nebulizer mask not dated lying inside R34's nightstand. R34 stated that he gets nebulizer treatments every day and as needed.On 4/28/2026 at 12:10 PM V2 (Director of Nursing) stated that nebulizer mask should be dated when it is changed or when therapy is initiated. It should be changed weekly or as needed (e.g. (for example), if visibly dirty). The reason is for infection control regarding the nebulizer mask getting dirty and contaminated. On 4/29/2026 at 11:12 AM V11 (Registered Nurse) stated that nebulizer masks are usually changed and dated by Sunday night shift nurses. V11 also stated that if she sees any mask that is visibly dirty or not dated, she will change and date it. The purpose of this is infection control practice.R34's admission Record documents diagnoses which…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-30 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 reconcile control substance form and maintain an accurate account of the controlled substance record for one resident (R38) reviewed for controlled substance in a sample of 21 residents.Findings include:On 04/28/26 at 12:35pm reviewed 3rd floor medication cart with V4 (Registered Nurse/RN). R38's controlled substance form for phenobarbital 64.8mg (milligrams) showed quantity remaining as 28. 27 tablets observed.R38's physician's order dated 04/21/26 documents in part, Phenobarbital oral tablet 64.8mg. Give 1 tablet by mouth one time a day for seizures.On 04/28/26 at 12:35pm V4 (RN) stated that she forgot to sign the narcotic sheet when she removed R38's medication. V4 stated that not signing out narcotics when removing them could create a count discrepancy and/or diversion. On 04/29/26 at 3:25pm V2 (Director of Nursing/DON) stated that the purpose of signing the controlled substance form is to make sure that all narcotics are accounted for. V2 stated that If the nurse doesn't sign out narcotics at the time of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-30 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to properly store respiratory equipment in a sanitary manner to help prevent transmission of disease and infection. This failure could potentially affect 1 (R18) resident reviewed for infection prevention and control in a sample of 21.On 04/27/2026 at 12:27PM surveyor and V2 (Director of Nursing/Infection Preventionist, DON/IP) entered R18's room and observed R18 awake in bed. A suction machine inside a plastic bag was observed laying on the floor next to a chair. An oxygen mask with oxygen tubing inside a plastic bag was observed laying on the floor next to the suction machine. Surveyor asked V2 if suction machine and oxygen mask with tubing should be on the floor and V2 said, No. V2 took suction machine and oxygen mask with tubing out of R18's room.R18's Brief Interview for Mental Status (BIMS) dated 04/10/2026 documents R18 with a score of 00 which indicates that R18's cognition is severely impaired.R18's face sheet shows that R18 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-18 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that one resident (R1) had an informed signed consent prior to administering a psychotropic medication. Findings include:R1 is an [AGE] year old with diagnosis including but not limited to: Alzheimer's disease, Delirium due to known physical condition, unspecified lack of coordination, difficulty in walking and essential hypertension. R1 has a BIMS (Brief Interview of Mental Status) score of 7, which indicates severe cognitive impairment. On 9/17/25 at 12:57 pm, R1 was observed sitting in his room with his daughter. At that time, V9 (R1's Family) said the following, They (facility) were giving my father Trazadone and I asked that they discontinue the Trazadone because once, I came here and he (R1) was very lethargic and looked like a zombie. When I asked what he had, I was told that he had Melatonin and Trazadone for sleep the previous night. Melatonin alone is just fine for my father to sleep. He is [AGE] years old. Why would they give my…
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 · D2025-09-18 · 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 implement and revise the resident-centered care plan for a resident with a diagnosis of urinary tract infection and hernia which affected one resident (R1) in the sample of 20 residents reviewed for care plan revision. Findings include:R1's admission Record documents, in part, diagnoses of urinary tract infection (UTI), Delirium, Benign Prostatic Hyperplasia with lower urinary tract symptoms Muscle weakness, difficulty in walking, chronic kidney disease stage 3, Essential hypertension, Unspecified Glaucoma, Alzheimer's, Anxiety, Malignant neoplasm of splenic.R1's Minimum Data Set (MDS), dated [DATE], documents, in part, a Staff Assessment for Cognitive Skills for Daily Decision Making is coded at 7 which is severe cognitive impairment. R1's Care Plan Report dated 8/5/2025 has no documentation stating care of UTI or hernia was observed in chart. On 9/18/25 at 10:56am, V6 ( MDS coordinator/Nurse) stated all diagnosis are care planned to ensure that staff…
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 · D2025-09-18 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide showers to a resident. This failure affected one resident (R1) reviewed for ADLs (activities of daily living) in a sample size of 20 residents. The findings include:On 9/17/25 at 12:52 PM, R1's white board in room displayed the dates that he was assigned to receive showers from facility staff, the dates listed were every Sunday and every Wednesday. R1 was eating his lunch at time of observation, his hair presented as oily and food debris were observed on his clothing.On 9/17/2025 at 12:57 PM, V9 (family member of R1) was in the room with R1 and stated that the facility has only provided R1 a shower once since admission and she knows this because she is always at the facility or has a caregiver present as a companion for R1 when she is not available.On 9/17/2025 at 1:24 PM, V8 (Certified Nursing assistant, CNA) entered the room of R1 to collect the food tray of R1, V8 stated he did not give R1 a shower. V8 stated I gave R1 a bed…
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 before2025-02-06 · 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 and interview, the facility failed to have signage posted identifying a resident who has oxygen in use in the resident's room to prevent a possible hazard. This affected one resident (R12) in a total sample of 21 residents. Findings include: On 02/03/2025 at 10:45am surveyor observed an oxygen tank, contained in a stand, sitting on the floor in R12's room. No Oxygen in Use sign posted on the outside of R12's door indicating that oxygen was in use in R12's room. On 02/03/2025 at 11:45am V1(Director of Nursing) stated, yes, there should be a sign on the door indicating that oxygen is in use in R12's room. On 02/05/2025 at 10:30am V1(Director of Nursing) stated the nursing staff are responsible for placing the Oxygen in Use sign on the resident's room door if the resident requires and receives an order for oxygen. V1 stated the sign is to be placed on front of the resident's door or there is a magnetic sign the staff can place on the door frame. V1 stated if the resident or family smokes in a room with oxygen; this can be a fire hazard. R12's diagnosis includes,…
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 5 citations
- Potential for harm · Fcited before2024-01-26 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews the facility failed to ensure kitchen staff wearing hair restraint while in the kitchen and failed to ensure frozen meats were stored six inches above the floor in the freezer. These failures have the potential to affect 22 residents in the facility who are receiving oral diet. Findings Include: On 1/23/24 at around 9:36 AM, during the initial tour in the kitchen, V15 (Utility Worker) was observed handling the dishes in the dishwashing machine area. V15 had short length hair on V15's head and was not wearing any hair restraint. At 9:49 AM, the main freezer was inspected with V14 (Director of Dining) and observed a frozen packed beef brisket and a frozen packed beef eye round on the floor under the shelving unit. V14 stated that foods should not be stored on the floor. V14 placed both packages of meat back at the bottom of the shelf in the freezer. At 9:56 AM, V14 stated that anyone who enters the kitchen especially kitchen staff should wear hair net or hair restraint to keep any loose hair falling off on to the food. On 1/24/24…
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 before2024-01-26 · 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 follow their policies and procedures to ensure proper infection control guideline practices are followed related to Personal Protective Equipment (PPE) was not worn prior to entering a contact/droplet isolation room for 1 (R20) out 4 residents reviewed for transmission-based precautions in sample of 12. This failure has the potential to affect all 22 residents residing in the facility. Findings Include: On 01/23/24 at 10:42 AM, surveyor noticed R20's door was closed with droplet/contact isolation sign for staff and visitor was posted on the front of R20's door. Surveyor observed V9 R20's son entered R20's droplet/contact isolation (Covid-19) room with surgical mask but without the proper Personal Protective Equipment (PPE) gown, gloves, N95 mask, and face shield. Surveyor called V8 (Certified Nursing Assistant) and asked V8 if it is proper for V9 to enter R20's room without PPE. V8 stated it is not proper for V9 to enter R20's room (Covid-19) without the PPE, V9 can be infected and pass it to others. V8 then…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-26 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to follow their policies and procedures to ensure a resident received their medications according to the physician's order for 1 (R20) out of 3 residents reviewed for pharmaceutical services in a sample of 12. Findings Include: On 1/23/24 at 11:30 AM, during record review surveyor observed V20 has order for antibiotic starting from 1/18/24 to 1/22/24 for Zithromax 250 MG tablet, to give 2 tablets on the first day, then 1 tablet daily for 4 days was administered until 1/23/24. On 1/23/24 at 11:50 AM, R20 stated, R20 has received medications this morning. On 1/24/24 at 9:50 AM, V12 (Registered Nurse) stated V12 discontinued the medication (Zithromax 250mg tablet) this morning (1/24/24). V12 stated the medication was signed off in the medication administration record yesterday (1/23/24). On 01/24/24 at 10:50 AM, V2 (Director of Nursing) stated that the medication (Zithromax 250 MG Tablet) was administered on 1/23/24, V2 agreed the medication should have been discontinued after the dose of 1/22/24. Nursing note dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-26 · 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 (a) properly date opened multi-dose eyedrops for 1 (R9) resident and (b) ensure that medication was stored properly in the correct medication packaging and for the right resident for 2 (R2 and R9) residents. These failures could potentially affect 2 (R2 and R9) residents from one of one medication carts inspected for medication storage and labeling. The findings include: R2's health record documented admission date 12/8/23 with diagnoses not limited to Acute and chronic respiratory failure with hypoxia, Chronic right heart failure, Chronic lymphocytic leukemia of b-cell type not having achieved remission, Unspecified atrial fibrillation, Essential (primary) hypertension, Malignant neoplasm of unspecified kidney, Chronic kidney disease, Other pulmonary embolism with acute cor pulmonale, Dyspnea, Other allergic rhinitis. R9's health record documented admission date 11/15/23 with diagnoses not limited to Periprosthetic fracture around internal prosthetic right hip joint, Mild persistent asthma, Dementia in other…
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 · D2023-08-05 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to immediately report an allegation of abuse and failed to protect one of two residents, (R1) reviewed for abuse. Findings include: Review of facility's abuse investigation (Investigation summary and conclusion) dated 6.16.2023 documents in part: On June 15. 2023, Dining Staff Member (V4-Server) made allegation that she saw CNA (V3-Certified Nursing Assistant) pinch the arm of resident (R1) in dining room last Saturday (6.10.2023). V4 who made the allegation did not report anything on day of the alleged incident but rather waited 5/several days, only expressing her concern, and reporting it when she saw resident rubbing his right arm. Employee believed that the alleged harm may still be happening given resident was rubbing his arm. At the time of interview, employee could not give details of her observation of the pinching except that it occurred after the resident slid off his chair and the pinching was done to his right arm. V3 (CNA) denied allegation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| SISTERS OF MERCY OF THE AMERICAS, INC | Organization | 5% OR GREATER SECURITY INTEREST | since 06/01/2022 |
| BARRETT, JOHN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 07/01/2023 |
| CONNELLY, KEVIN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 03/01/2017 |
| CYPSER, DELORES | Individual | CORPORATE DIRECTOR | since 07/01/2018 |
| FLANAGAN, ANNA | Individual | CORPORATE DIRECTOR | since 07/01/2018 |
| HOULIHAN, NANCY | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 07/01/2025 |
| JOHNSON, MARGARET | Individual | CORPORATE DIRECTOR | since 07/01/2017 |
| KNIGHTLY, EILEEN | Individual | CORPORATE DIRECTOR | since 07/01/2025 |
| LACHOWICZ, FRANCES | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/17/2015 |
| O'CALLAGHAN, DARLENE | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 07/01/2023 |
| SHEEHAN, CAROLYN | Individual | CORPORATE DIRECTOR | since 07/01/2023 |
| WALTON, JOHN | Individual | CORPORATE DIRECTOR | since 07/01/2025 |
| TRINITY CONTINUING CARE SERVICES | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/15/2025 |
| TRINITY SENIOR SERVICES MANAGEMENT | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/02/2025 |
| HENDRICKS, GINNY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/2025 |
| PALER-DOMINGUEZ, CAROLYN | Individual | ADP OF THE SNF | since 10/20/2025 |
CMS files one row per role, so the 25 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $517K paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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 2024. 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, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 146174. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-30, 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.