Whitehall Of Deerfield
300 Waukegan Road, Deerfield, IL 60015 · For profit - Corporation · 190 certified beds · (847) 945-4600 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — 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 (28) — 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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 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 | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 fell from 4 to 3 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 | 21.7% | 13.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 10.2% | 6.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 3.3% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.5% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 46.0% | 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 | 0.5% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 17.2% | 14.3% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 13.5% | 18.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 91.7% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 10.7% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 33.9% | 20.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 13.0% | 21.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.2% | 2.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 68.7% | 63.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 25.6% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 11.9% | 13.9% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.93 | 2.02 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.62 | 2.22 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
67.0% 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 1,668 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 63.9% 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 697 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 0.93 therapist hours per resident per day in 2026Q1 — more than 96% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 36% 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 | 67.0%CMS range 65.0–69.0 | 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 | 9.7%CMS range 8.0–11.3 | 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 | 63.9% | 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 | 52.5% | 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 | 63.0% | 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 | 99.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 99.1% | 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 | 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 | 0.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.8% | 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 | 5.2%CMS range 3.9–6.2 | 7.1% | Oct 2023–Sep 2024 | better than U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.91 | 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 190 beds and averages 132.3 residents a day — about 70% occupied, or roughly 58 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.64 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.34 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.41 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.51 hrs/resident/day on weekends vs 4.70 on weekdays — 4% thinner on weekends. RN hours go from 1.34 to 1.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 42% is about the same as 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.
28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.
- Potential for harm · Dcited before2026-05-06 · 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 ensure fall interventions were in place for a resident at high risk for falls for 1 of 3 residents (R3) reviewed for safety and supervision in the sample of 3.The findings include:R3's Fall Risk Evaluation dated 4/29/26 shows that she is at high risk for falls. R3's Minimum Data Set assessment dated [DATE] shows that her cognition is impaired and requires substantial/maximal assistance to sit to stand, transfer and walk.R3's Incident Report dated 4/29/26 shows, At 2:30 AM patient is sleeping comfortable in bed resting, and when medication pass was for her at around 5:15, nurse observed patient on the floor, head towards the foot of the bed.Resident unable to give description.R3's Fall Care Plan shows an intervention initiated on 5/6/26 for: Please keep high floor mats in place on both sides of bed as appropriate- date initiated 4/29/2026.On 5/6/26 at 11:10 AM, R3 was laying in bed. R3 did not have fall mats next to her bed or in her room.…
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 before2026-01-20 · 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 ensure staff performed hand hygiene and wore and/or changed personal protective equipment (PPE) in a manner to prevent potential exposure to and transmission of contagious diseases. These failures have the potential to affect all 151 residents living in the facility.The findings include:The facility's Facility Data Sheet dated 1/20/26 shows their current census is 151.The facility's 1st Floor Census sheet dated 1/20/26 shows R2, R3, and R4 are each positive for COVID-19.The facility's Isolation Tracking sheet dated 1/19/26 shows R2 tested positive for COVID-19 on 1/14/26, R3 tested positive for COVID-19 on 1/17/26 and R4 tested positive for COVID-19 on 1/16/26. They were each placed on contact/droplet isolation on the day they tested positive.On 1/20/26 at 10:40 AM, V10, Certified Nursing Assistant (CNA), went to R2's room wearing a surgical mask. V10 then put a N95 mask over the surgical mask along with other PPE (gloves, face shield, and gown) and entered R2's room. R2's room was marked with a sign for N95…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-04-23 · tag F0803 — failed to meet residents' dietary needs — widespreadEnsure 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
Based on observation, interview, and record review the facility failed to ensure facility recipes were followed. This has the potential to effect all residents receiving food from the kitchen. The findings include: The Centers for Medicare and Medicaid Services form 671 shows there are 131 residents residing in the facility. Facility provided list of residents that have an order of NPO (Nothing by Mouth) show there are three residents with an order of NPO that do not receive food from the kitchen. Facility provided menu week at a glance shows on 4/21/25 the noon meal includes beef barley soup, turkey and Swiss cheese sandwich, three bean salad, and mandarin oranges. 1. On 4/21/25 9:48 AM, dietary staff were seen scooping three bean salad from a bulk container into portion cups for the noon meal. The staff member was using a 4 ounce (oz) slotted spoodle with a green handle. On 4/21/25 at 11:20 AM, the mandarin orange portion in the portion cups being placed on resident trays appeared small. On 4/21/25 at 12:02 PM, V3 (Food Service Director) measured both the mandarin orange and three…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-04-23 · 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 ensure safe food handling procedures were being practiced. This has the potential to effect all residents receiving food from the kitchen. The findings include: The Centers for Medicare and Medicaid Services form 671 shows there are 131 residents residing in the facility. Facility provided list of residents that have an order of NPO (Nothing by Mouth) show there are three residents with an order of NPO that do not receive food from the kitchen. 1. On 4/21/25 at 9:53 AM, V4 (Dietary Aide) and V5 (Dietary Aide) were breaking down breakfast trays on one side of the dirty side of the dish machine counter. V6 (Dietary Aide) was wearing gloves and was placing plates, utensils, trays, and other items into dish racks and running them through the dish machine on the opposite side of the dish machine counter from V4 and V5. V6 went over to the clean and sanitized of the dish machine, moved dish racks out of the way to allow more dish racks to run through the dish machine, then went to the sink attached to the dirty side…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-04-23 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure insulin pens and tuberculin purified protein derivative (PPD) were labeled with open and with expiration dates, and failed to ensure medications were stored securely for 5 of 10 residents ( R78, R16, R384, R385 and R386) reviewed for medication labeling/storage in the sample of 27. The findings include: On [DATE] at 11:03 AM, in the 2nd floor medication cart there were 2 insulin pens open that were not dated and 1 insulin pen that had expired on [DATE]. These were identified as flextouch insulin pens belonging to R78 which included one expired pen and one unlabeled pen, and a unlabeled Humalog kwik pen belonging to R16. At 11:03 AM while checking the medication cart V10 (Registered Nurse/ RN) said insulin pens should be labeled when they are opened and have the expiration date also, which would be 28 days later. V10 said all expired pens or medications should be immediately removed from the medication cart and disposed of. On [DATE]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-04-23 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure enhanced barrier precautions (EBP) were in place and failed to change gloves and perform hand hygiene in a manner to prevent cross contamination for five of 27 residents (R30, R51, R383, R382, R376) reviewed for infection control in the sample of 27. The findings include: 1. R30's admission Record dated April 22, 2025 shows she was admitted to the facility on [DATE] with diagnoses including dysphagia, osteomyelitis, cognitive communication deficit, pressure injury of sacral region, and attention to gastrostomy (Percutaneous endoscopic gastrostomy tube/feeding tube/G tube). R30's Order Summary Report shows she has an indwelling catheter drainage bag and has a wound dressing change to her sacrum. R30's orders do not include an order for enhanced barrier precautions. R30's Care Plan initiated on February 20, 2025 shows, [R30] is on enhanced barrier precaution related to g-tube. On April 22, 2025 at 11:20 AM, R30 was observed in her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-23 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to treat a resident in a dignified manner for one of 27 residents (R51) reviewed for dignity in the sample of 27. The findings include: R51's admission Record shows he was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, pneumonitis, difficulty in walking, need for assistance with personal care, dysphagia, depression, and anxiety disorder. On April 21, 2025 at 12:17 PM during the lunch meal, R51 was sitting in his high back recliner. V21 Activity Coordinator was standing in front of R51 spooning thickened liquids and pureed food into R51's mouth. V21 was not sitting down within eye to eye level of R51. On April 23, 2025 at 9:13 AM, V1 Administrator said staff should be sitting down while feeding residents so they are able to engage with the residents. V1 said an inservice was provided to staff in regards to sitting while feeding residents. The facility's Privacy and Dignity Policy revised August 16, 2024…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-23 · 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
Based on observation, interview, and record review the facility failed to monitor weights for a resident with weight loss and failed to apply compression stockings for a resident with a history of blood clots which applies to 2 of 2 residents (R96, R5) reviewed for quality of care in a sample of 27. The findings include: 1. R96's Facesheet printed on 4/23/25 showed R96 is an eighty-three year old female resident readmitted to the facility from a hospital stay on 3/24/25 with diagnoses which included: Parkinson's disease, acute post hemorrhagic anemia, stage 3 sacral pressure ulcer, dysphagia, mild protein-calorie malnutrition, and malignant neoplasm of pancreas. R96's medical record showed a readmission weight of 160 pounds on 3/24/25. R96's previous weight of 2/8/25 was 171 pounds. This is a 6.4% difference. On 4/21/25 R96's weights were reviewed. These were the only 2 weights in R96's vitals section. R96's Order Summary Report printed on 4/22/25 showed an order for weekly weights to be done every Monday. The order start date is 3/24/25. On 4/22/25 at 1:46 PM, V18 Clinical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-23 · 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 observation, interview, and record review the facility failed to ensure pressure relieving interventions were in place for residents at risk for developing pressure injuries for three of six residents (R276, R26, R51) reviewed for pressure injuries in a sample of 27. The findings include: 1. R276's Facesheet printed on 4/22/25 showed R276 is an eighty-five year old male resident admitted to the facility on [DATE] with diagnoses which include: type 2 diabetes mellitus, peripheral vascular disease, unstageable sacral pressure ulcer, and needing assistance with personal care. R276's Braden Skin Assessment summary printed on 4/23/25 showed R276 has been at High Risk for developing pressure injuries since his initial assessment on 4/10/25. On 4/21/25 at 11:20 AM and 1:20 PM R276 was lying in with his legs/heels directly on the mattress. On 4/22/25 at 9:50 AM R276 was in the same possition with no heel offloading devices in place. R276's legs had reddened areas along the calf area. R276 stated the reddened…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-23 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure interventions were in place to prevent a contracture from getting worse for one of 27 residents (R69) reviewed for range of motion in the sample of 27. The findings include: R69's admission Record shows he was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis, dysphagia, and pressure injury of sacral region. R69's facility obtained picture shows that R69 had a rolled wash cloth to his left contracted hand. On April 21, 2025 at 10:08 AM, 10:52 AM, and 1:11 PM R69's left hand was contracted and bent up on his chest. There were no devices in place to R69's contracted hand. On April 23, 2025 at 9:13 AM, V2 Director of Nursing (DON) said R69 should have a rolled washcloth in place to his contracted hand. V2 said the rolled wash cloth is used to help prevent further injury to his left hand. The facility's Restorative Nursing Program revised August 19, 2024 shows, Appropriate nursing and restorative…
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 18 citations
- Potential for harm · Dcited before2025-04-23 · 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 ensure medications were administered according to professional standards. This applies to 1 of 27 residents (R380) reviewed for pharmacy services in the sample of 27. The findings include: On 4/22/25 at 9:02 AM, R380 was lying in bed watching television. On R380's bedside table on the right side of R380's bed there was a small plastic cup that contained two pills. R380 said the pills were mycophenolate and R380 has to take them on an empty stomach. R380 said she did not eat breakfast until almost 9:00 AM on 4/22/25 and was holding them to take around 9:30 AM. R380's Order Summary Report dated 4/23/25 shows R380 has an order for mycophenolate, take two tablets by mouth one time a day for organ transplant. R380's Order Summary Report does not show R380 has orders to self-administer medications. On 4/23/25 at 9:13 AM, V2 (Director of Nursing) said the normal procedure of providing a resident medications includes introducing themselves to the resident, answering any questions about the medications that 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 · D2025-04-23 · 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 interview and record review the facility failed to administer a pneumococcal vaccine to 1 of 5 residents (R26) reviewed for immunizations in the sample of 27. The findings include: R26's face sheet shows she was admitted to the facility on [DATE]. R26's Immunization Report shows she was administered a Pneumococcal Conjugate Vaccine 13 (PCV13) on 10/20/18. There are no additional documented Pneumococcal vaccines in R26's Immunization report or any documented refusals of Pneumococcal vaccines in her Electronic Medical Record. On 4/23/25 at 12:22 PM, V14 (Assistant Director Of Nursing) said R26's second dose of her Pneumococcal vaccine a Pneumococcal Polysaccharide Vaccination 23 (PPSV23) should have been administered 1 year after her dose given on 10/20/18 but it was missed. The facility provided Pneumococcal Vaccination Policy last revised on 9/16/24 shows after receiving a PCV13 a person over age [AGE] should also receive a PPSV23 1 year after the PCV 13, or they could receive newer option (added after…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-18 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the interview and record review, the facility failed to ensure that a resident's caregiver immediately reported a new injury of unknown origin for 1 of 1 residents (R1), who were reviewed for injuries of unknown origin in the sample of 4. The findings include: R1's current care plan showed that R1 was nonverbal, severely cognitively impaired, completely dependent on staff for all care, and unable to move her lower extremities without staff assistance due to her diagnosis of senile degeneration of the brain. A progress note for R1, dated 12/9/24, showed, Writer was notified by caregiver of bruise on left big toe, slightly swollen . Per caregiver, weekend caregiver identified the incident but did not report to the nurse on duty at the time . ordered X-ray of left foot. Site slightly warm to touch, no grimacing or pain elicited upon site palpation . R1's left foot X-ray report dated 12/10/24 showed results of acute intra-articular corner fracture at the lateral margin of the left great toe . R1's bruise/injury of unknown origin report showed R1 was unable to state what…
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 before2024-12-18 · 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
Based on interview and record review the facility failed to provide cares to a resident in manner that prevented a resident injury. The facility failed to ensure a resident was transferred via mechanical lift in a safe manner. These failures apply to 1 of 4 residents reviewed for safety and supervision in the sample of 4. The findings include: R1's current care plan showed R1 was nonverbal, severely cognitively impaired, completely dependent on staff for all cares, and unable to move her lower extremities without staff assistance due to her diagnosis of senile degeneration of the brain. A progress note for R1, dated 12/9/24, showed, Writer was notified by caregiver of bruise on left big toe, slightly swollen . ordered X-ray of left foot. Site slightly warm to touch, no grimacing or pain elicited upon site palpation . R1's left foot X-ray report dated 12/10/24 showed results of acute intra-articular corner fracture at the lateral margin of the left great toe . R1's bruise/injury of unknown origin report showed R1 was unable to state what happened to her left toe due to her poor…
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 · D2024-12-03 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 did not inform/invite a resident's representative to a care plan meeting for 1 of 3 residents (R1) reviewed for care plans in the sample of 3. The findings include: R1's face sheet showed he was admitted to the facility on [DATE] and V8 (R1's Mother) was R1's guardian. The same document showed R1 was diagnosed with lack of expected normal physiological development in childhood and autistic disorder. On 12/2/24 at 11:15 AM, V8 said she was R1's Power of Attorney and had not been informed by the facility of a care plan meeting, care planning process, or attended any care plan meeting/conference. On 12/3/24 at 11:03 AM, V7 (Director of Social Services) was asked when R1's care plan meeting was. V7 did not give an exact date and said R1's care plan meeting took place throughout his stay at the facility. V7 said residents and their representatives are verbally informed when care plan meetings are scheduled. On 12/3/24 at 11:20 AM, V2 (Director of Nursing) said…
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 before2024-05-30 · 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 observation, interview, and record review the facility failed to change gloves while using the dishwasher and failed to sanitize food thermometers in a manner to prevent cross contamination. This applies to all residents residing in the facility. The findings include: The CMS 671 form dated 5/28/24 showed 139 residents residing in the facility. 1. On 5/28/24 at 10:31 AM, V14 (Dietary Aide) was wearing gloves while loading dirty dishes into the dishwasher. V14 wore the same gloves to dip a test strip into the 3-compartment sink. V14 returned to the dishwasher and continued loading dirty dishes. V14 was observed repeatedly loading and unloading dishes while wearing the same contaminated gloves. On 5/29/24 at 1:47 PM, V12 (Dietary Manager) stated dirty dishes should be rinsed and loaded into the dishwasher by one person then another person puts the clean items away. If the same person is loading and unloading, they need to change gloves or wash their hands in between. It prevents the dishes from getting dirty. The items can get contaminated with bacteria. Staff need clean…
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 before2024-05-30 · 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 ensure residents followed smoking contracts for 2 of 2 residents (R24 & R27) reviewed for safety, supervision, and smoking in the sample of 28. The findings include: 1. On 5/30/24 at 10:18 AM, R27 was in a covered area, outside, sitting in a wheelchair wearing gray sweats, black tennis shoes and a hat. R27 did not have a smoking apron on. V4 (Life Enrichment Director) was standing outside observing R27 while she was smoking. V4 stated the smoking schedule was on the arm pad of R27's wheelchair. R27 moved her arm, and it showed the smoking times were 10:00 AM, 1:30 PM, and 4:15 PM. R27 stated she keeps her cigarettes in the bottom drawer in her room. V4 stated the nurse keeps R27's lighter. V4 stated R27 is supposed to wear a smoking apron and should have one on. R27 stated she would wear a smoking apron. R27 stated she has not refused to wear a smoking apron. The Smoking Contract dated 3/21/24 for R27 showed, if facility determines that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-30 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure indwelling urinary catheter tubing was not laying or dragging on the floor for 1 of 3 residents (R434) reviewed for indwelling urinary catheters in the sample of 28. The findings include: On 5/28/24 at 11:48 AM, R434 was sitting in a high back wheelchair in the common area of the dining room. R434 had an indwelling urinary catheter, and the tubing was laying on the floor. R434 was propelling his wheelchair back and forth and the tubing was dragging on the ground. At 11:56 AM, V5 (Registered Nurse) pushed R434 to the dining room table with his catheter tubing dragging on the floor. On 5/29/24 at 11:01 AM, V2 (Director of Nursing) stated the catheter tubing should not be on the floor for infection control. V2 stated there would also be a chance that the tubing would get pulled out. The Face Sheet dated 5/29/24 for R434 showed medical diagnoses including chronic obstructive pulmonary disease, atherosclerosis, sick sinus syndrome,…
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 before2024-05-30 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident took their medications. This applies to 1 of 1 resident (R79) reviewed for medication administration in the sample of 28. The findings include: R79's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include rheumatoid arthritis, neurocognitive disorder with Lewy bodies, dementia without behavioral disturbance, hypertension, chronic kidney disease, cardiac arrhythmia, and anxiety disorder. R79's facility assessment 4/19/24 showed she has moderate cognitive impairment. R79's current Physician Order Sheet showed an order for Telmisartan 40 MG, Give 1 tablet by mouth two times a day for hypertension . On 5/28/24 at 10:50 AM, R79 was in her room sitting on her bed. R1 had a medication cup on her bedside table that had a white pill in it. There were powdery pill fragments in the cup as well. R79 said, I had a bunch of pills, this is the only one left. There were two white ones, I had one that 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 · D2024-05-30 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure a resident's soup was nectar thick for 1 of 4 residents (R68) reviewed for thickened liquids in the sample of 28. The findings include: On 5/29/24 at 11:38 AM, R68 was sitting in his wheelchair at the dining room table and V6 CNA (Certified Nursing Assistant) put R68's tray in front of him and removed the lids to his food and soup. V6 walked away and R68 began feeding himself. R68 had garden vegetable soup in a coffee cup that appeared to be a thin liquid. At 11:49 AM, V6 was asked to check R68's soup. The thickener was at the bottom of the coffee cup and not mixed into the soup to make it nectar thick. V6 stirred the soup, and it did not become nectar thick. V6 stated he had additional thickener available, went and got the thickener and added more to R68's soup. V6 stated he did not know why R68 was on nectar thick liquids. R68 was asked if he knew why he had thickened liquids and he stated, Because I eat a lot. R68 was asked if he had any problems swallowing and he stated, No. The meal ticket 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 before2024-04-30 · 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 ensure interventions/hip precautions were used to keep a resident's left hip prosthetic in place. This applies to 1 of 3 residents (R1) reviewed for quality of care in the sample of 3. The findings include: R1's EMR (Electronic Medical Record) shows that R1 was admitted to the facility on [DATE] with diagnoses including Periprosthetic Fracture around Internal Prosthetic Left Hip Joint, Difficulty in Walking, Chronic Obstructive Pulmonary Disease, Parkinson's Disease and Dementia. R1's Progress Notes dated 3/9/24 state, Received patient in bed Alert and Oriented x 1-2. Patient complained of increased pain to left hip 10/10. Oxycodone (Narcotic Analgesic) given at this time. (Physician) covering for (Primary Physician) made aware of increased pain with order for STAT X-Ray to left hip. (Portable X-Ray) made aware of STAT order. Called into patient's room upon assessment noted bloody drainage to surgical incision site and raised bump to left hip proximal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-30 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an injury of unknown origin was investigated for 1 of 4 residents (R2) reviewed for injuries in the sample of 11. The findings include: On 10/30/23 at 2:40 PM, V9 (R2's caregiver) said R2 had a bruise about the size of a quarter to the middle of R2's forehead which wasn't there the previous day. V9 said she has a picture of the bruise, and she reported it to the nurse. V9 stated she doesn't remember nurse's name, but she was not a regular nurse, she was agency on 9/10/23. V9 said the wound was definitely a bruise, not a scratch, and it took weeks to heal. V9 said the nurse told her she was going to make a report. V9 said R2 was nonverbal and couldn't tell what happened. On 10/30/23 at 12:37 PM, V4 (Registered Nurse/RN) said R2's caregiver told her there was a bruise to R2's head. V4 said the nurses who work in the facility all the time said the bruise had been there on the evening shift the day prior, but there wasn't anything documented in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-06-07 · tag F0803 — failed to meet residents' dietary needs — patternEnsure 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
Based on observation, interview, and record review, the facility failed to follow the facility's menu and recipe for residents on puree diet for eight of eight residents (R21, R22, R27, R43, R50, R72, R82, and R357) reviewed for pureed diets in the sample of 25. The findings include: The facility's Diet Type Report dated 6/7/23 shows R21, R22, R27, R43, R50, R72, R82, and R357 are on a puree texture diet. The facility's Week 1 Daily Spreadsheet shows residents on pureed diets are to receive pureed beef barley soup, pureed turkey, and cheese, pureed hot vegetable, pureed peach cobbler, and two slices of pureed bread. The recipe for pureed beef barley soup shows, Place prepared beef barley soup in food processor and blend to a smooth consistency. The recipe for pureed turkey sandwich, no lettuce/tomato shows, place portion of turkey sandwich filling in food processor with cold milk. Do not add lettuce or tomato. Blend to smooth consistency. On 6/5/23 at 10:30 AM, V7 (Cook) took turkey deli meat and pureed it. V7 added a small amount of hot water to thin out the pureed deli turkey…
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 before2023-06-07 · 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 — the official record, unedited, may be distressing
Based on interview and record review the facility failed to record daily weights per physician orders for a resident with congestive heart failure for 1 of 25 residents (R2) reviewed for quality of care in the sample of 25. The findings include: R2's Care Plan showed R2 had congestive heart failure (CHF) and was at risk for altered cardiovascular functioning related to CHF. The same care plan showed under interventions to, Obtain labs and weights as ordered. R2's Order Summary Report showed an order for daily weights. R2's Weights and Vitals Summary and Treatment Administration Record showed from 5/3/23-6/5/23 weights were not recorded for 8 days (5/6/23, 5/9/23, 5/10/23, 5/15/23, 5/20/23, 6/3/23, 6/4/23, and 6/5/23). On 06/06/23 at 09:29 AM, R2 said she had CHF and did not get weighed every day. On 06/06/23 at 11:47 AM, V5 (Licensed Practical Nurse) said for a resident with CHF weights are done as ordered. V5 added the reason for tracking weights is to monitor for fluid overload.
- Potential for harm · Dcited before2023-06-07 · 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 observation, interview, and record review the facility failed to ensure pressure relieving interventions were in place for 1 of 5 residents (R7) reviewed for pressure wounds in a sample of 25. The findings include: R7's Facility assessment dated [DATE] showed R7 is a [AGE] year-old female resident with a history of pressure wounds and needing extensive assistance with bed mobility and transfers. On 6/5/23 at 10:45 AM, R7 was lying in bed on her back. R7 stated she had previously broken her leg and has a difficult time moving in bed. R7's heels were resting directly on the mattress with no pillow or offloading device present. R7 stated she had previously had pressure wounds and they took a while to heal. At 1:10 PM R7 was in the same position. On 6/6/23 at 10:45 AM, V13 (Physical Therapist/Wound Team) stated R7 has had wounds in the past. R7's skin is thin and needs to be protected. R7's Braden assessment dated [DATE] showed R7 is at risk for developing pressure wounds. R7's Physician Orders printed on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-07 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to offer additional pain medication for a resident with pain for 1 (R405) of 25 residents reviewed for pain in the sample of 25. The findings include: 1. R405's Face Sheet shows diagnoses of: Multiple fractures of ribs, left side, and hemothorax. R405's Physician's Order Sheet shows orders for Tylenol extra strength 500 milligrams (MG) every 6 hours as needed for pain and tramadol 50 MG every 6 hours as needed for moderate pain. On 6/5/23 at 10:05 AM, R405 complained of pain at a level 7 on a pain scale of 0-10. R405 said that the pain was located at her back left rib area. V10 (Registered Nurse/RN) gave R405 Tylenol 500 milligrams (MG) for the pain. At 1:45 PM, R405 said that her pain was at a level 7. At that time, V10 entered the room and said that she can only have Tylenol every 6 hours and she just gave her some with her morning medications. V10 did not offer any additional pain medications. R405 was then provided Physical Therapy. On 6/6/23 at 1:05 PM, V8 (RN) said that pain medication is administered per…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-07 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, and record review, the facility failed to administer medications at the ordered time and ordered dosage. There were 31 opportunities with 2 errors resulting in a 6.45 % error rate. This applies to 1 of 5 residents (R405) observed in the medication pass. The findings include: 1. R405's June Medication Administration Record (MAR) shows an order for slow-release iron 50 milligrams (MG) daily at 9:00 AM and an order for acyclovir 800 MG five times a day for viral infection for 7 days with a start date of 6/5/23 at 9:00 AM. On 6/5/23 at 10:05 AM, V10 (Licensed Practical Nurse) administered R405 her 9:00 AM medications. V10 administered iron 65 MG and did not administer acyclovir. On 6/6/23 at 1:05 PM, V8 (Registered Nurse) said that all medications should be given at the ordered time (one hour before to one hour after). V8 said that the nurse should verify with the MAR on dosage of all medications before administering.
- Potential for harm · Dcited before2023-06-07 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review facility staff failed to wear appropriate PPE (personal protective equipment) in a contact isolation room for a resident and failed to place a resident on contact isolation with a suspected shingles outbreak. This applies to 2 of 25 residents (R356, R405) in the sample of 25. The findings include: 1. On 6/5/2023 at 11:50AM, V6 (Certified Nursing Assistant/CNA) was observed in R356's room assisting the R356 out of the bathroom. V6 was observed to be wearing gloves only, with no gown present on V6. There was a contact isolation sign observed which was posted to the right side of the resident's door. A black cart with isolation supplies was observed to the right of the resident's door blow the contact isolation sign. On 6/5/2023 at 11:56AM, V6 said she was assisting R356 out of the bathroom. V6 said she only had gloves on. V6 said she did not know why R356 was on isolation. V6 said she did not see a sign outside of the resident's room. V6 said gown and gloves should be worn when entering a contact isolation room. On 6/7/2023 at 9:40AM,…
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 LEGACY HEALTHCARE — 89 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 | 3 of 5 | 2.9 | +0.1 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 4 of 5 | 2.5 | +1.5 vs chain |
| Quality measures | 3 of 5 | 3.3 | -0.3 vs chain |
The other 88 homes this chain runs (chain average 2.9★, per CMS)
Showing 40 of 88; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| DOROS GENERATION TRUST U/A/D 1/3/12 | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 20% | since 08/22/2022 |
| GPN FAMILY TRUST U/A/D 4/28/08 | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 48% | since 08/22/2022 |
| OAKWAY OPERATIONS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 12% | since 08/22/2022 |
| RAJCHENBACH 2015 FAMILY TRUST | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 20% | since 08/22/2022 |
| FORBRIGHT BANK | Organization | 5% OR GREATER SECURITY INTEREST; OPERATIONAL/MANAGERIAL CONTROL | — | since 08/22/2022 |
| WH NORTH PROPERTY, LLC | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | — | since 08/22/2022 |
| SHABAT, MENACHEM | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/22/2022 |
| LEGACY HEALTHCARE FINANCIAL SERVICES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/22/2022 |
| COHEN, CINDY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/22/2022 |
| SULTAN, JOHN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/22/2022 |
| RSM US LLP | Organization | ADP OF THE SNF | — | since 01/01/2024 |
CMS files one row per role, so the 18 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.
8 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 $2.5M 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 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145706. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-23, 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.