St Joseph Village Of Chicago
4021 West Belmont, Chicago, IL 60641 · Non profit - Corporation · 54 certified beds · (773) 328-5500 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- it has 3 actual-harm citations
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- nursing-staff turnover (57%) runs well above the national median (45%)
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 | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 2 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 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 5.8% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.7% | 6.3% | 5.4% | typical |
| 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 | 0.0% | 54.2% | 6.5% | check this* — see note marked star 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 | 3.1% | 3.1% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 0.0% | 14.3% | 16.1% | check this* — see note marked star below the table |
| Long-stay residents on antianxiety or hypnotic medication | 6.6% | 18.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 95.8% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.5% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 31.5% | 20.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 23.4% | 21.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.1% | 2.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 79.2% | 63.1% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 24.9% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 13.6% | 13.9% | 12.0% | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
54.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 222 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 52.3% 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 132 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 0.51 therapist hours per resident per day in 2026Q1 — more than 82% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 20% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| 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 | 54.2%CMS range 46.2–60.6 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.6%CMS range 7.8–13.8 | 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 | 52.3% | 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 | 58.3% | 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 | 37.9% | 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 | 99.5% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 98.8% | 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 | 1.1% | 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 | 1.1% | 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 | 6.8%CMS range 4.0–10.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.11 | 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 54 beds and averages 52.4 residents a day — about 97% occupied, or roughly 2 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 4.62 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.36 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.93 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 4.17 hrs/resident/day on weekends vs 4.80 on weekdays — 13% thinner on weekends. RN hours go from 1.45 to 1.13 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 57% is well above 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.
25 citations, most serious first. The 13 most serious are shown; the remaining 12 are one tap away and print in full.
- Actual harm · Gcited before2026-05-08 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record reviews, the facility failed to follow their policy to ensure significant weight loss is prevented in the facility for one (R5) out of three residents reviewed for nutrition in a sample of 14. This failure resulted in R5 not receiving suggested supplements and experiencing severe weight loss.Findings include:On 05/06/2026 at 12:12 PM, surveyor reviewed R5's weights from 10/2025 to 04/2026.R5's weight documents in part:03/01/2026: 128.2 lbs.02/01/2026: 131.5 lbs.01/05/2026: 137.6 lbs.12/09/2025: 150 lbs.12/03/2025: 145.0 lbs.11/05/2025: 147.8 lbs.10/02/2025: 147.6 lbs.Based on documented weights, R5 has a 13.1% weight loss in a 6-month period from 10/2025 to 03/2026Based on documented weights, R5 has 9.3% weight loss in a 3-month period from 12/2025 to 02/2026.Based on documented weight, R5 has a 5.1% weight loss in a 1-month period from 12/2025 to 01/2026.On 05/06/2026 at 2:18 PM, V13 (Dietician) stated that when she gets an alert of any weight loss or changes, she looks into their diet, what they are consuming, and looks if we have any supplements.…
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 · G2024-06-14 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to put interventions in place for a newly admitted resident (R199) in a sample of 12 residents. This failure resulted in R199's skin intact with redness progressed to stage three wounds of the buttock and heel. Findings include: According to R199's face sheet printed 6/12/2024, R199 is [AGE] years of age and was admitted to the facility on [DATE] and discharged [DATE]. R199 diagnoses include but are not limited to aftercare following explanation of shoulder joint prosthesis; unspecified rotator cuff tear or rupture of left shoulder; arthropathies, left shoulder; polyosteoarthritis; pressure-induced deep tissue damage of left heel and right buttock with onset date 5/10/24; pressure ulcer of left heel and right buttock, stage 3 with onset date 5/22/24. R199's admission Evaluation, dated 5/10/2024, indicates skin intact. According to R199's POS (Physician Order Summary) printed 6/12/24, the following orders were placed for R199, air loss mattress, order date…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-06-14 · 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 interviews and review of records the facility failed to provide effective supervision, interventions and monitoring to prevent falls per policy for a resident that needs maximal assistance with ADLs/Activities of Daily Living (bed mobility, transfers, and ambulation). Facility also failed to ascertain or to rule out injury had occurred due to the fall. These failures include 1 out of 1 resident (R49) in a total sample of 12 residents reviewed for accidents and hazard. This failure resulted in R49 having 2 falls for a period of 6 days in the facility. R49 sustained left leg/hip severe pain and left leg/hip (femoral) fracture that was determined the day after discharge. Findings include: R49 was [AGE] years old, admitted on [DATE] for respite of 6 days until 1/29/2024. R49 medical diagnosis includes vascular dementia, convulsion, cerebral atherosclerosis. R49's progress notes for history and physical by V4 (Medical Doctor) dated 1/25/2024 documents that R49 was seen confused alert to self only. R49 needs…
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 before2026-05-08 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to follow proper sanitation and food storage practices as evidenced by a.) food not properly labeled, b.) food not properly stored, and c.) not practicing effective handwashing. These deficient practices have the potential to affect 52 residents receiving food prepared in the facility kitchen. Findings include: On 05/05/2026 at 9:39AM during initial kitchen tour with V4 (Dining Services Director) and V5 (Chef), the following food items were found in the walk-in cooler: 1 opened carton of eggs, no open date, no use by date, and not labeled with the food item.1 tray of sliced onions, green peppers, and red peppers wrapped in clear plastic wrap, no preparation date, no use by date, and not labeled with the food item.1 bowl of beef steak wrapped in clear plastic wrap, no preparation date, no use by date, and not labeled with food item.1 opened container of sliced limes wrapped in clear plastic wrap, with a use by date of 05/04/2026.1 opened container of potatoes cut in halves inside of a water solution, no use by…
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 before2026-05-08 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, facility failed to follow their policy to ensure medications are immediately removed from the locked medication storage area and disposed of for medications that are unlabeled and without secure closure. This failure has the potential to affect all the residents on the 2nd floor.Findings include:On [DATE] at 12:37 PM, surveyor reviewed the medication cart on the 2nd floor. There was only one medication cart. Surveyor opened the top drawer on the medication cart and saw a pill cup with no name, room number or closure, with unknown and unidentified medications in the pill cup.On [DATE] at 12:38 PM, V8 (Registered Nurse) stated that she thinks these are blood pressure pills but not fully sure. V8 stated that medications are to be discarded and not stored in the medication card without proper closure and labeling.On [DATE] at 11:40 AM, V2 (Director of Nursing) stated) that medications stored in the medication cart are already pre-packaged. The medication should…
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 · E2026-05-08 · tag F0880 — failed to prevent and control infections — patternProvide 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 utilize appropriate PPE (Personal Protective Equipment) in a contact precaution room which affected two residents (R2, R30) reviewed for infection control in a total sample of 15 residents reviewed. The Facility also failed to follow their policy to ensure proper hand washing prior to medication administration for three (R13, R5, R19) out of five residents reviewed for medication administration in a total sample of 15 residents. Findings include: On 05/05/2026 at 11:16 AM, surveyor observed there was a contact isolation signage on the R2's door. Surveyor observed the door open, there was a family member inside the room with no gown, gloves. There was a staff member inside the room, with no gown or gloves. On 05/05/2026 at 11:30 AM, surveyors observed there was a family member in V30's room, not wearing proper PPE in a contact isolation room. On 05/05/2026 at 11:43 AM, V7 (Certified Nurse's Aide) stated she was not sure what the contact isolation signage at the door was for. V7 stated all that she was told 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 · Dcited before2026-05-08 · 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 review of records, the facility failed to correctly assess resident limitation and failed to follow their policy on using safety equipment for fall prevention of 1 out of 1 resident (R13) reviewed for accidents and hazards for a total of 15 residents in the sample. These failures have the potential to affect safety of 1 resident (R13) with history of falls.Findings include:R13 is a resident in facility initially admitted on [DATE]. Per clinical record, R13 had a fall in the facility on 04/03/2026. R13 went to hospital diagnosed with left femur/upper leg fracture due to mechanical fall. R13 readmitted in facility on 04/08/2026.On 05/05/2026 at 01:22 PM, R13 was seen inside her room lying on the bed. R13 was alert, verbally responsive and able to express thoughts within topic during conversation. R13 stated that she was waiting to go to therapy. V20 (Certified Nursing Assistant) went inside the room and spoke to R13 about scheduled therapy. V20 went out of the room for a few…
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 before2026-05-08 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to change oxygen tubing and reservoir for one resident (R23) reviewed for oxygen therapy in a total sample of 15 residents.Findings include: On 05/05/2026 at 12:41PM, R23 observed lying down in bed receiving oxygen therapy via nasal cannula with oxygen tubing connected via oxygen concentrator. Surveyor observed that R23's nasal cannula oxygen tubing was labeled with two dates 04/27/26 and 05/03/26. Surveyor also observed that R23's humidifier was connected to the oxygen concentrator and labeled with a date of 04/27/26.On 05/05/2026 at 1:10PM, V8 (Registered Nurse/RN) now located inside of R23's room and observes that R23's nasal cannula tubing was labeled with two dates of 04/27/26 and 05/03/26. V8 also observes that R23's oxygen humidifier is dated 04/27/26. V8 states she is not sure why R23's oxygen tubing is labeled with two dates. V8 states she did not label the oxygen tubing or humidifier. V8 states she is not sure who labeled the tubing since there are no initials labeled. V8 states resident's oxygen…
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 before2026-05-08 · 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 observations, interviews, and record reviews failed to follow their policy to ensure controlled medications are documented for 1 (R34) out of the 4 residents reviewed for narcotics reconciliation in a sample of 15.Findings include:On 05/05/2026 at 12:40 PM, surveyor observed R34's Modafinil bingo card (medication card). R34's Modafinil bingo card shows a count of 13.R34's Modafinil Controlled Drugs Receipt/Record/Disposition Form documents in part: Count is 14.On 05/05/2026 at 12:40 PM, V8 (Registered Nurse) stated that she is supposed to document in the Controlled Drug Receipt/Record Form when the controlled medication is administered. V8 stated that she administered the medication but forgot to document right away.On 05/06/2026 at 11:40 AM, V2 (Director of Nursing) verified that R34's bingo card did not match R34's Modafinil Controlled Drugs Receipt/Record/Disposition Form. V2 stated that it is important to document administered controlled medications to reconcile and maintain the accuracy of the documentation. You have to document in order to track the time, date given,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-08 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to offer an influenza vaccine to a newly admitted resident. This failure affects one resident (R40) in a total sample of 15 residents reviewed.Findings include:On 05/06/2026 at 11:44 AM, surveyor is with V3 (Infection Control Nurse), reviewing immunization records. This surveyor noted R40 was admitted on [DATE], reviewed immunizations records for R40, there is no evidence of R40 receiving an influenza vaccine. There is no record of R40 being offered or declining the Influenza vaccination. V3 stated since R40 was admitted during the peak of the end of the season, R40 did not need the influenza vaccine.On 05/06/2026 at 2:15 PM, V2 (Director of Nursing/ DON) stated if a resident was admitted on [DATE], the resident should had been offered an influenza vaccination. V2 stated the nurse will educate the resident on the vaccine being offered, and hand a consent form before administering the vaccine. V2 stated the flu season is considered from…
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 before2025-07-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement interventions consistent with a resident's needs and current professional standards of practice to eliminate the risk of a fall for one (R1) resident out of six residents reviewed for quality of care in a total sample of six. This failure resulted in R1 sustaining a fall without significant injury. Findings include: On 07/08/2025, at 1:23 PM, V3 (Certified Nursing Assistant/CNA) stated that she was the assigned CNA for R1 when R1 fell on [DATE]. V3 stated that V3 was going around taking blood pressures and meal tickets. V3 stated I went to his room and he needed something. I told him to give me a second. I am going to take vital signs. I will be right back. At that time he kept getting up and I instructed him to lay back down, and he followed that command. I went to go get another resident's vital signs. When I came to his room, I heard him yell. I heard him say hey. When I looked in his room he was on the ground. V3 stated that R1 had a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-29 · 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 interview and record review, the facility failed to meet personal care and nursing needs; and failed to ensure that a resident received treatment and care in accordance with professional standards of practice and in accordance with the resident's goals of care for one resident (R1) in a total sample size of three residents. Findings include: Facility's undated investigation form documents in part, At this time, it appears that V7 did not do appropriate rounding, nor did V7 make appropriate inquiries about the care needed for R1. V7's time sheet shows a late arrival to V7's shift. V7 also did not inquire about R1's needs from the nurse on duty. On 08/27/24 at 11:38am, V7 Certified Nursing Assistant (CNA) stated, I (V7) didn't get any report about R1. I (V7) didn't know that R1 needed help or assistance with feeding or being cleaned. I (V7) helped clean R1 when R1's daughter came. Before that I (V7) didn't clean R1 because I (V7) didn't think R1 needed me to do anything. When I (V7) cleaned R1 with R1'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 before2024-08-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide adequate supervision for one resident (R2). This failure affected one resident (R1) and has the potential to affect all residents residing on the 3rd floor. Findings include: R1 has a diagnosis of but not limited to Chronic Obstructive Pulmonary Disease, Hypertensive Heart, Rheumatoid Arthritis, History of Falling, Pressure Ulcer of Right Hip, stage 3, Pressure Ulcer of Right Upper Back, Stage 4, Pressure Ulcer of Left Upper Back, Stage 4. R1 has a Brief Interview of Mental Status score of 09. R2 has a diagnosis of but not limited to Dementia, Hypertensive Heart Disease, Dementia, Type 2 Diabetes Mellitus, Cognitive Communication Deficit, Anxiety Disorder. R2 has a Brief Interview of Mental Status score of 04. R2's Minimum Data Set, dated [DATE] documents, in part, Sit to Stand: Substantial/Maximal Assistance (Helper does More Than Half the effort), Chair/bed to chair transfer: Partial/Moderate assistance (Helper does Less Than…
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 12 citations
- Potential for harm · Fcited before2024-06-14 · 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, interview, and review of record the facility failed to properly store and label fruits and vegetables inside walk-in cooler. And failed to seal properly burger patties and processed turkey chili inside walk-in freezer in accordance with policy of the facility. These failures are potential to affect all 42 residents taking food by mouth. Findings include: On 06/11/2024 at 09:45 AM, with V23 (Food Services Director) at the walk-in cooler 1 discolored cantaloupe not dated. V23 said, I do not think this is mold, but I see what you mean. I will discard it. V23 took the discolored cantaloupe out of the walk-in cooler. Celery labelled as received May 15 with no other date when to discard. There are onions and carrots on a plastic container (not the original package) not dated. At the walk-in freezer turkey chili and around 27 burger patties on a large metal tray, at the bottom plastic wrap not attached from three sides exposing the food to the environment. V23 was asked if these patties are intended to be prepared for residents' consumption. V23 took the metal tray…
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 before2024-06-14 · 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 follow policy to reconcile controlled medications in order to prevent loss or diversion for one of two carts reviewed for medication labeling and storage. Findings include: On 6/11/24 at approximately 10:00 AM, reviewed 1st floor medication cart: -Observed the number of pills in three bingo cards did not match the corresponding number of pills left on the Controlled Drug Receipt/Record/Disposition forms. The controlled substance was not signed out by the nurse when administered. R150 POS (Physician Order Summary) documents in part: hydromorphone HCL tablet 5mg. R150 Hydromorphone HCL 4mg bingo card indicates 19 pills remaining. R150 Controlled Drug Receipt/Record/Disposition Form for Hydromorphone HCL 4mg indicates amount left is 20. R24 POS documents in part: oxycodone HCL tablet 5mg and pregabalin capsule 75mg. R24 Pregabalin 75mg bingo card indicates 2 pills remaining. R24 Controlled Drug Receipt/Record/Disposition Form for Pregabalin 75mg indicates amount left is 3. R24 Oxycodone HCL 5mg bingo card…
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 before2024-06-14 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to a) remove medications from the top of the cart when unattended, b) lock the cart when unattended and c) remove expired medications from the cart for one of two medication carts reviewed for medication labeling and storage. Findings include: On 6/11/24 at approximately 10:00 AM, reviewed 1st floor medication cart: -During medication administration with V14 (Nurse), a medicine cup of approximately 10 loose tablets and capsules for a resident was observed on the top of the medication cart that was unattended. -During medication administration with V14, V14 walked away from the medication cart and went into a resident room leaving the medication cart out of view of V14. The cart was observed not locked. -Observed Lantus (insulin glargine) injection pen 100unit/ml, not sealed, labeled with date opened 5/6 and date expire 6/3/24. R23's POS (Physician Order Summary) documents in part: Lantus SoloStar subcutaneous solution pen-injector (insulin glargine). -Observed a controlled substance, a bottle of Hydromorphone…
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 · D2024-06-14 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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 initiate a new Level I screen for residents with known mental illness for one (R12) resident reviewed for Pre-admission Screening and Record Review (PASARR) in a total sample of 12 residents reviewed. Findings include: R12's Facehsheet documents that R12 was admitted to the facility on [DATE]. R12's Facesheet documents that R12 was diagnosed with other bipolar disorder on 05/17/2022, and diagnosed with major depressive disorder, recurrent, unspecified on 05/17/2022. R12's Interagency Certification of Screening Results OBRA-I Initial Screen dated 04/11/2018 indicates that R12 has no reasonable basis for suspecting MI (mental illness). R12's Minimum Data Set (MDS) Section I dated 03/15/2024 indicates active diagnoses of depression and bipolar disease. There is no documentation to show that R12 has a Level II PASARR screening. On 06/12/2024, surveyor inquired to V1 (Administrator) about level PASARR screenings for residents who are admitted 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 · Fcited before2023-05-26 · 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 observation, interview, and record review, the facility failed to follow their policy and procedure for food and supply storage to ensure food and dairies in the main cooler were discarded after the expiration date. This failure has the potential to affect 42 residents in the facility who are receiving oral diet. Findings include: On 5/23/23 at 9:28 AM, during the initial kitchen tour with V4 (Dining Services Director), the following were found in the main cooler: a container of cooked mushrooms labeled today's date 5/15 and good thru 5/15. V4 stated, I think it's expired already. It needs to be thrown out. Also found 5 half gallons of whole milk labeled with best by dates of May 19. V4 stated, They are expired and should have been thrown out, they should have been thrown out on Friday. V4 stated if residents are served with expired foods, they could potentially get illness. On 5/24/23 at 10:22 AM, interviewed V13 (Registered Dietitian) and stated that expired foods and dairies should be removed and disposed of from the main cooler. V13 stated that foods and dairies with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-26 · 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 to provide turning and repositioning for a dependent resident (R28) for 1 of 20 residents reviewed for improper nursing care. Findings include: R28's comprehensive care plan documents in part that R28 has potential impairment to skin integrity related to poor mobility and history of pressure injury. Focus, initiated 01/06/2022, documents in part that R28 presents with weakness in bilateral lower extremities and limitation in right lower extremity. Intervention initiated 01/06/2022 documents in part: BED MOBILITY: The resident requires extensive assistance by one staff to turn and reposition in bed. R28's Quarterly MDS (Minimum Data Set) dated 03/31/2023 documents in part that R28 requires extensive assist with one-person physical assist. R28's Braden Scale for Predicting Pressure Sore Risk dated 04/01/2023 documents in part that R28 is at risk for developing pressure sores. On 05/23/2023 at 10:28 AM, surveyor observed R28 lying in bed on [R28's] back with the head of the bed elevated less than 90 degrees 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 before2023-05-26 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 enteral feedings as prescribed by physician for 1 (R40) of 3 residents reviewed for nutrition in a total sample of 22. Findings include: On 05/24/23 at 10:10 AM, surveyor observed tube feeding IsoSource 1.5 formula in plastic bag with R40's tube feeding infusing at 50 milliliters/hour (ml/hr.) and tube feeding formula bag labeled with R40's name, room number, date 05/23/23, time 7:00 PM, total volume 1000 milliliters, rate 50 milliliters/hour. V22 (R40's Family Member) stated a member of R40's family is at the facility daily from morning to early evening and that R40's tube feeding is routinely turned off at 12 noon so that R40 can receive therapy downstairs. On 05/24/23 at 10:52 AM, V5 (7-3 Registered Nurse/RN) stated R40 receives tube feedings and nothing by mouth. V5 stated V5 turns off and removes R40's tube feeding at 12 noon so R40 can participate in physical therapy downstairs. V5 stated R40's tube feeding is off between 12…
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 before2023-05-26 · 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 follow their policy and procedure for oxygen administration to ensure that oxygen is administered under orders of a physician. This failure has the potential to affect one (R245) of three residents reviewed for respiratory care in a sample of 22. The findings include: R245 admission date was on 5/22/23 with diagnoses not limited to Displaced Intertrochanteric fracture left femur status post intramedullary nail/ORIF (open reduction internal fixation), History of falling, COPD (Chronic Obstructive Pulmonary Disease), Paroxysmal Atrial Fibrillation, Unspecified Dementia without behavioral disturbance, Essential Hypertension, Atherosclerotic heart disease. On 5/23/23 at 10:29 AM, R245 was observed sitting in wheelchair, alert and verbally responsive. R245 stated, I think I was admitted last night. R245 was observed with oxygen inhalation at 2L/min via nasal cannula. At 11:10 AM, V5 (Registered Nurse -RN) was interviewed and stated she (V5) was the assigned nurse to R245. V5 stated that R245 is currently using…
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 before2023-05-26 · 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 discard expired medications from their medication carts for 3 residents (R9, R29, R30) in 2 out of 2 medication carts reviewed in a sample of 20 residents. Findings include: On 05/23/2023 at 2:21 PM, surveyor reviewed the third-floor medication cart with V10 (Nurse). Observed R9's Atropine Sulfate 1% solution in the drawer. Open date 02/24/2023. Staff did not write a date in the expired section of the label. V10 stated for ophthalmic solutions, they should be discarded after 28 days from open date. Observed R30's Ear Wax Removal Drops 6.5% solution in the drawer. Open date 2/10/2023. No written expired date. V10 stated it should have been discarded 4 weeks after open date. Facility's Medication Storage in the Facility policy, dated March 2021, documents in part: Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmic, nitroglycerin tablets, blood sugar testing solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiration…
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 · D2023-05-26 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the 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 the meal ticket menu for 1 (R22) of 3 residents reviewed for nutrition in a total sample of 20 residents. Findings include: On 5/23/23 at 11:47 AM, R22's eating lunch in her room. R22's meal tray consisted of pureed chicken salad, pureed orzo, pureed ginger soup, pureed cake, and coffee. R22's meal ticket shows R22 was supposed to receive 4 ounces (oz) of pureed roll wheat and 4 oz of pureed peaches. R22's meal ticket also shows that R22 is allergic to milk. R22's physician order sheet shows R22 is on puree texture, thin liquid consistency and lactose free diet. R22's Minimum Data Set (MDS) dated [DATE] shows R22 is cognitively impaired. At 11:53 AM, V17 (Dietary Aide) stated that for dessert residents get cake and no peaches. V17 also stated the kitchen has no pureed roll wheat and pureed peached prepared. At 11:55 AM, V4 (Dining Services Director) stated that residents should receive what's on their meal ticket. On 5/24/23 at…
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 · D2023-05-26 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide a sanitary elevated toilet seat for 1 (R95) out of a total sample of 20 residents reviewed for homelike environment. Findings include: On 05/23/2023 at 11:23 AM, R95 returned from therapy. V8 (Physical Therapy Assistant) pushed R95 in a wheelchair back to room. Shortly after, V8 and R95 returned to the nurses' station and headed to the spa room next to the nurses' station. V7 (Certified Nurse Aide), who was sitting at the nurses' station, asked what is wrong. V8 stated R95 did not want to use the raised toilet seat because it was rusted. V7 stated [V7] will call for a new one and replace it. At 11:39 AM, R95 was back in the bedroom. Surveyor entered for interview. R95 was alert and oriented to person, place, and time. R95 stated [R95] did not want to use the raised toilet seat so [R95] asked V8 to take [R95] to use the one in the spa room. R95 pointed to the raised toilet seat in [R95's] bathroom. R95 stated, Would you want to use that thing. Look at it. It's all rusted. Rust on the metal brims under…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2026-05-08 · tag F0638 — patternAssure that each resident’s assessment is updated at least once every 3 months.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of records and interviews, the facility failed to provide required MDS (Minimum Data Set) discharge assessment for 1 out of 1 resident (R55) reviewed for resident assessments. These failures are not according to CMS instruction and affected 1 resident (R55) in determination of proper tracking of resident placement, monitoring and records.Findings include:On 05/06/2026 at 2:15 PM, an inquiry about R55 present location was made to V1 (Administrator/Executive Director). V1 after checking records, stated that R55 currently resides on assisted living but was in the skilled nursing facility in December. V1 stated that R55 was discharged on 12/27/2025, but MDS staff did not do discharge assessment.Per census list, R55 was admitted in the facility on 12/12/2025 and was discharged on 12/27/2025.Per CMS's RAI Version 3.0 Manual dated 10/2025:Discharge Assessment refers to an assessment required on resident discharge from the facility, or when a resident's Medicare Part A stay ends, but the resident remains in the facility (unless it is an instance of an interrupted stay, as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to FRANCISCAN COMMUNITIES — 6 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 4.0 | +1.0 vs chain |
| Health inspection | 4 of 5 | 2.8 | +1.2 vs chain |
| Staffing | 5 of 5 | 4.5 | +0.5 vs chain |
| Quality measures | 3 of 5 | 4.2 | -1.2 vs chain |
The other 5 homes this chain runs (chain average 4.0★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| STARK, JAMES | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 02/19/2014 |
| UMANSKIY, REGINA | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 07/05/2022 |
| ROSENBERGER, ROBERT | Individual | CORPORATE OFFICER | since 04/11/2023 |
| D'SOUZA, GODWIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2022 |
| HARRIS, LADON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/11/2023 |
CMS files one row per role, so the 9 rows in the source record cover these 5 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.
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 $531K 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 145637. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-08, 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.