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Crescent Care Of Elgin

180 South State Street, Elgin, IL 60123 · For profit - Limited Liability company · 88 certified beds · (847) 742-3310 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 immediate-jeopardy citation$44,709 in federal fines1 Medicare payment denial
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
Worth asking about
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $44,709 in federal fines (most recent 2023-11-16)
  • its payroll-based staffing rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
370 Summit St · (847) 608-1344 · Call to confirm hours
Pharmacy
Oportun0.5 mi
27 Times Square Road Clock Tower Plz · (847) 416-6868 · Call to confirm hours
Grocery
59 S Grove Ave · (224) 535-8060 · Call to confirm hours
Park
132 S Grove Ave · (847) 931-6100 · Typically dawn to dusk
Place of worship
ICF Elgin0.2 mi
2600 Hopps Rd · (847) 280-0723

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 5 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 improved from 2 to 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.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased3.9%13.4%15.4%better
Long-stay residents who lose too much weight8.5%6.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.3%0.9%0.9%better
Long-stay residents with a urinary tract infection0.0%1.5%2.0%better
Long-stay residents with depressive symptoms87.5%54.2%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.7%3.1%3.3%better
Long-stay residents whose ability to walk worsened2.5%14.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication13.8%18.3%18.9%better
Long-stay residents given the seasonal flu vaccine98.7%91.8%95.3%typical
Long-stay residents with pressure ulcers3.3%4.8%4.7%better
Long-stay residents with worsening bladder/bowel control25.7%20.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table20.8%21.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.1%2.2%1.4%better
Short-stay residents given the seasonal flu vaccine84.4%63.1%79.4%typical
Short-stay residents rehospitalized after admission24.6%26.1%22.6%typical
Short-stay residents with an outpatient ER visit13.2%13.9%12.0%typical
Long-stay hospitalizations per 1,000 resident days2.292.021.67worse
Long-stay outpatient ER visits per 1,000 resident days1.152.221.80better

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.

48.7% 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 42 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

48.7%U.S. median 51.5%
Got home and stayed home
9.4%U.S. median 10.7%
Went back to hospital
59.3%U.S. median 56.6%
Met the expected recovery
0.32U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.08hours / resident / day
Speech therapy

Met the expected recovery: 59.3% 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 27 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 0.32 therapist hours per resident per day in 2026Q1 — more than 52% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 33% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF48.7%CMS range 32.9–62.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.4%CMS range 6.6–13.010.7%Oct 2022–Sep 2024no 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 discharge59.3%56.6%Oct 2024–Sep 2025CMS 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 discharge63.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge51.9%50.0%Oct 2024–Sep 2025CMS 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 identified100.0%98.7%Oct 2024–Sep 2025CMS 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 setting100.0%100.0%Oct 2024–Sep 2025CMS 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.9%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.8%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.2%CMS range 4.3–13.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.391.02Oct 2022–Sep 2024CMS 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

0.71
RN hours/ resident / day
0.80
LPN hours/ resident / day
1.95
Aide hours/ resident / day
3.46
Total nurse hours/ resident / day
0.56
RN hoursweekends
41.3%
Total nursing turnover
23.1%
RN turnover

How full it usually is: this home is certified for 88 beds and averages 70.9 residents a day — about 81% occupied, or roughly 17 beds typically open. It usually has some room. 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 3.46 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.71 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.95 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.87 hrs/resident/day on weekends vs 3.71 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 0.77 to 0.56 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 41% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

5
deficiencies at the latest standard inspection (2025-12-04)
5
at the previous standard inspection (2024-09-12)

Deficiencies are unchanged from the previous inspection. 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.

ABCDEFGHIJKL

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.

23 citations, most serious first. The 12 most serious are shown; the remaining 11 are one tap away and print in full.

  • Immediate jeopardy · Kcited before2023-11-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure 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

    There are multiple deficient practice statements. A. Based on observation, interview and record review the facility failed to ensure water temperatures in resident bathrooms were maintained at a safe level to prevent potential resident injury. This failure resulted in the water in five residents' bathrooms measuring 150(+) degrees Fahrenheit, having the potential to cause third degree burns within 1-2 seconds, at 12:40 PM on 11/13/23. This applies to 5 of 5 residents (R16, R17, R38, R53 and R55) reviewed for safety in the sample of 22. B. Based on observation, interview and record review the facility failed to ensure a resident on a mechanically altered diet was safely assisted to eat for 1 of 22 residents (R39) reviewed for safety in the sample of 22. The findings include: A. The Immediate Jeopardy began on 11/13/23 at 12:40 PM when V3 (Maintenance Director) and Surveyor checked the water temperature in 5 residents' bathrooms on the second floor of the facility. Using the facility's thermometer, the temperatures measured 150.1-150.2 degrees Fahrenheit. V1 (Administrator) 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2023-11-16 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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 have ordered pressure reducing interventions in place to prevent R72's stage 2 sacral pressure wound from deteriorating to a stage 3. R72's pressure wound increased in size and depth and worsened in condition. This applies to 1 of 3 residents (R72) reviewed for pressure wounds in the sample of 22. The findings include: R72's Minimum Data Set Assessment of 9/24/23 shows that R72 was admitted to the facility on [DATE] with diagnoses including Renal Insufficiency, Neurogenic Bladder and Paraplegia. This same assessment shows that R72 had a stage 2 pressure ulcer (wound) present upon admission. On 11/14/23 at 8:45 AM R72 was lying in bed awake. R72 was alert and oriented. R72 stated that he gets up sometimes but really doesn't have any motivation to get out of bed. R72 stated that he walked into the hospital, and they had to wheel him out. He stated that he is unable to walk and usually just prefers to stay in bed. R72's Initial Wound…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-12-04 · tag F0947 — failed to train nurse aides adequately — widespread
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    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 the required twelve (12) hours per year of continuing competence training for Certified Nursing Assistant (CNAs), including dementia management training. This failure has the potential to affect all 68 residents, as indicated in the facility's Centers for Medicare and Medicaid Services (CMS) Form 671, Long-Term Care Facility Application for Medicare and Medicaid report of their current census. The findings include:On 12/2/2025 at 10:20 AM, review of the facility's Certified Nursing Assistant (CNA) orientation packet showed no evidence of dementia-related in-services. V16 (Human Resources Coordinator) stated dementia training hours are not something she tracks, nor was she told that dementia training was required for CNAs to work on the floor. A sample review of three CNA personnel files also showed no documentation of dementia training. On 12/3/2025 at 11:54 AM, V19, V20, and V21 (CNAs) stated they do not keep track of their annual training hours. When asked about specific training topics completed in the past…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-04 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure 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 label residents' medications when opened. This applies to 4 out of 4 (R79, R65, R63, and R17) residents reviewed for medication storage in a sample of 22.The findings include:1. On 12/03/2025 at 8:20 AM, the facility's first-floor medication cart #2 was checked with V5 (Registered Nurse/RN). R79's Symbicort aerosol inhalers were opened and not labeled with open or discard dates.R79's Order Summary Report dated 12/03/2025 showed an active order for Symbicort Inhalation Aerosol 160-4.5 MCG/ACT 2 puff inhale orally two times a day.2. On 12/03/2025 at 8:20 AM, the facility's first-floor medication cart #2 also had R65's Fluticasone aerosol inhaler was opened and not labeled with an open or discard date. V5 said she was unsure why the opened inhalers were not labeled. R65's Order Summary Report dated 12/03/2025 showed an active order for Fluticasone-Umeclidinium-Vilanterol 1 inhalation inhale orally one time a day.3. On 12/03/2025 9:30 AM, the facility's second-floor medication cart #1 was checked with V6 (RN).…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-04 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    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 obtain orders from the physician to have resident medication at the bedside. The facility also failed to complete self-administration of medication assessments. This applies to 3 of 3 residents (R1, R63, and R70) reviewed for medications in a sample of 22.The findings include: 1. On 12/01/2025 at 10:11 AM, the following medications were on R63's bedside table: Fluticasone Propionate Nasal Spray, Hydrocortisone ointment 1%, Atrovent (Ipratropium Bromide) inhaler, Spiriva Respimat inhaler (Tiotropium Bromide), Levalbuterol Tartrate (Xopenex inhaler). R63 stated that the medications are always kept in her room. She stated she has emphysema and chronic bronchitis. R63 said, No one told me how to do these inhalers or cream. I've been using these for years and I know how to do it. It's always kept here. Review of R63's POS (Physician Order Sheet) shows orders for the following medications: Fluticasone Propionate Nasal Suspension 1 spray in both nostrils two times a day for allergies, Hydrocortisone External…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-04 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to give residents and/or their POA (Power of Attorney) written notification for the reason of the transfer to the hospital. The facility also failed to provide a bed hold notice and notify the ombudsman. This applies to 2 of 4 residents (R5, R63) reviewed for transfers and discharges in a sample of 17. The findings include:1. R5's face sheet shows an original admission date of 12/4/25. R5's progress note dated 10/15/25 at 3:36 PM shows the following: (R5)'s BP (Blood Pressure) noted to be 73/39, Temperature 97.7, Pulse 109. Vital signs rechecked and BP 79/32, Pulse 66, Temperature 99.0, Respiration 18, and Oxygen Saturation 95% on room air. NP (Nurse Practitioner) in the building with new order to send (R5) to ER (Emergency Room) via 911 for further evaluation. Son and Daughter notified. 911 called. Approximately 3:30 PM, (R5) was transported to the hospital via 911. Report called to ER nurse.Review of R5's electronic medical record had no reason of transfer form or bed hold notice uploaded. Progress notes do not indicate…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-04 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to assess, monitor and obtain a treatment order for a resident with a known pressure wound. This affects 1 of 4 residents (R89) reviewed for pressure ulcers. The findings include:R89's face sheet documents admission date of 11/24/25. Diagnoses include surgical amputation of left foot due to foot ulcer, type II diabetes mellitus, hyperlipidemia, depression, obstructive sleep apnea, hypertension, atherosclerotic heart disease, atrial fibrillation, congestive heart failure, peripheral vascular disease and osteoarthritis. MDS (Minimum Data Sheet) dated 11/3/25 documents R89 has intact cognitive functions. R89 is totally dependent on two staff for transfers and needs partial/moderate assistance with bed mobility. On 12/1/25 at 10:35 AM, incontinence care was being provided by V7 (Certified Nursing Assistant/CNA), V8 (CNA) and V9 (CNA). When R89 was positioned on his left side, an undated bordered foam dressing was observed on R89's sacrum. The wound dressing appeared old and was peeling off from R89's skin. V9 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-02-11 · tag F0725 — failed to have enough nursing staff — widespread
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    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 sufficient staff to meet the ADL (Activities of Daily Living) needs of the residents in the facility. This applies to all 79 residents residing in the facility. The findings include: The Facility Data Sheet dated February 6, 2025 shows the facility census as 79 residents. 1. On February 10, 2025 at 9:14 AM, R1 was lying in bed in her room. R1 said, My brief is wet. I was changed at 3:00 AM this morning. No one has changed me since they started at 6:00 AM when the next shift got here. I just have to wait my turn because they tell me they have a lot of people to take care of. R1 continued to say she is always sure she has an absorbent under pad to sit on in her bed so when she soaks through her incontinence brief, her bedding does not get soiled. V10 (CNA/Certified Nursing Assistant) was outside of R1's room. V10 said she was assigned to care for R1. V10 said she was assigned to care for twelve residents. The EMR (Electronic Medical…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-02-11 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to provide a clean, homelike environment when it failed to provide window shades, or equivalent, that are in good repair, without stains or tears. This applies to 13 of 18 residents (R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, and R18) reviewed for lack of window shades/curtains and homelike environment in the sample of 18. The findings include: 1. On February 6, 2025 at 9:26 AM, R6 and R7 were sitting in their room. The window in their room had temporary, pleated paper shades over the window. The paper shades were torn. Plastic clips were in place to hold the shade open approximately 12 inches from the bottom of the windowsill. The residents said they are unable to raise and lower the shades to a height of their liking, so the shades remain held open with the plastic clips, in the same position. 2. On February 6, 2025 at 9:30 AM, R8 and R9 were sitting in the room they share at the facility. R8 and R9's room has a large window, approximately 5 feet wide by 5 feet high. R8 and R9's window faces the courtyard/patio…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide timely incontinence care. This applies to 2 of 3 residents (R1 and R4) reviewed for timely incontinence care in the sample of 18. The findings include: 1. On February 10, 2025 at 9:14 AM, R1 was lying in bed in her room. R1 said, My brief is wet. I was changed at 3:00 AM this morning. No one has changed me since they started at 6:00 AM when the next shift got here. I just have to wait my turn because they tell me they have a lot of people to take care of. V10 (CNA/Certified Nursing Assistant) was outside of R1's room. V10 said she was assigned to care for R1. V10 said she was assigned to care for twelve residents. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including rheumatoid arthritis, generalized anxiety disorder, insomnia, restless leg syndrome, major depressive disorder, anemia, and chronic pain syndrome. R1's MDS (Minimum Data Set) dated December 5, 2024 shows…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 and interview the facility failed to ensure electrical wires are not left exposed, near a resident's metal bed frame. This applies to 1 of 4 residents (R1) reviewed for safe environment in the sample of 18. The findings include: On February 6, 2025 at 9:15 AM, R1 was lying in bed in her room. The headboard of R1's bed was up against the wall of her room. The wall behind R1's bed had multiple areas of chipped plaster and paint. On the wall behind R1's headboard, approximately 4 inches from the floor, an electrical outlet box appeared damaged. The outlet box was hanging off the wall. The outlet box was open, and electrical wires were hanging outside of the outlet box. The electrical wires had multiple electric wire connectors in place on the ends of the electrical wires. The exposed electric wires were approximately two to four inches from R1's metal bed frame. R1 said, Oh, every time they boost me in the bed, the whole bed moves and bangs into the wall behind my bed. I know they hit 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-09-12 · tag F0880 — failed to prevent and control infections — widespread
    Provide 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 follow their water management plan. The facility also failed to follow their policy regarding catheter care to prevent infection and to follow Enhanced Barrier Precautions. The facility also failed to perform hand hygiene and glove changes during provisions of care. This applies to all 70 residents residing in the facility. The findings include: 1. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated September 9, 2024, showed the facility census was 70 residents. The facility's Water Management Program for Prevention of Legionella Growth dated June 27, 2023, showed Purpose: To identify and reduce the risk of Legionella growth and spread . Preventative maintenance will be performed as applicable: The following will be verified and documented at least once weekly: -The domestic hot water boiler/storage tanks verified to be set between 140 to degrees Fahrenheit. -Thermostat indicating the temperature of water…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · E2024-09-12 · tag F0887 — pattern
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    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 follow their policy to offer and administer the COVID-19 vaccine to residents. This applies to 4 of 5 residents (R1, R22, R32, and R39) reviewed for vaccinations in the sample of 18. The findings include: 1. The EMR (Electronic Medical Record) showed R1 was a [AGE] year-old resident, admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, asthma, alcoholic cirrhosis of the liver, heart failure, and type 2 diabetes mellitus. R1's Immunization Report showed R1's most recent COVID-19 vaccine was received on September 27, 2022. On September 11, 2024, at 1:37 PM, V11 (Nurse Consultant) said the facility follows CDC (Centers for Disease Control and Prevention) recommendations for COVID-19 vaccinations. V11 continued to say R1 should have been offered the 2023-2024 COVID-19 vaccine. The facility does not have documentation to show R1 was offered the 2023-2024 updated COVID-19 vaccine. 2. The EMR showed R22…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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 was anchored to prevent the catheter from being pulled, tugged, and avoid catheter related trauma. This applies to 1 of 1 resident (R64) reviewed for catheter care in the sample of 18. The Findings include: The EMR (Electronic Medical Record) showed that R64, a [AGE] year-old with diagnoses that includes but not limited to type 2 diabetes mellitus, malignant neoplasm of the prostate, history of urine infection with identified ESBL (Extended Beta Lactamase Spectrum) microorganism, osteoarthritis, congestive heart failure, anemia, diabetic neuropathy, lack of coordination and abnormalities of gait and mobility. R64 was admitted to the facility on [DATE]. The MDS (Minimum Data Set) dated 8/2/24, showed that R64 was cognitively intact. On 9/11/24 at 9:45 AM, R64 was complaining of pain and discomfort in his penis area. R64 was observed with an indwelling urinary catheter draining concentrated urine. R64 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-12 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop 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 follow their policy to offer and administer pneumococcal vaccines in accordance with CDC (Centers for Disease Control and Prevention) guidelines. This applies to 3 of 5 residents (R1, R22, and R32) reviewed for vaccinations in the sample of 18. The findings include: 1. The EMR (Electronic Medical Record) showed R1 was a [AGE] year-old resident, admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, asthma, alcoholic cirrhosis of the liver, heart failure, and type 2 diabetes mellitus. R1's Informed Consent for Vaccinations dated January 16, 2021, showed R1 consented to receive pneumococcal vaccinations. R1's Immunization Report showed R1 received the PPSV23 (23-valent Pneumococcal Polysaccharide Vaccine) on January 18, 2021. On September 11, 2024, at 1:37 PM, V11 (Nurse Consultant) said the facility follows CDC guidelines for pneumococcal vaccine timing and R1 should have been offered a second…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-11-16 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review, the facility failed to test and record the wash and rinse temperatures of their high temperature dishwasher three times a day. This failure has the potential to affect all 68 residents residing in the facility. The findings include: The facility CMS 671 dated 11/13/23 shows there are 68 residents in the facility. During the initial tour of the kitchen on 11/13/23 at 9:33 AM, the facility's Dish Machine Log-High Temp was reviewed for November 2023. No wash or rinse temperatures were recorded under Supper on 11/10/23, 11/11/23, or 11/12/23. On 11/15/23 at 10:05 AM, V17 (Dietary Manager) said she checks the dishwasher temperatures in the morning when she first arrives and before dishes from each meal service are washed. V17 said she will run an empty load first before proceeding to wash dishes in order to verify the temperature is in the correct temperature range. The Dish Machine Log-High Temp dated November 2023 shows, Instructions: Record wash and rinse temperature, and provide initials, three times per day.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-11-16 · tag F0880 — failed to prevent and control infections — widespread
    Provide 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 facility failed to ensure sure staff doffed PPE (personal protective equipment) in a manner to prevent cross-contamination after caring for COVID-19 positive residents. The facility failed to ensure 5 residents (R51, R58, R2, R15, R7) on contact/droplet transmission-based precautions had the required isolation signage outside of their rooms. The facility failed to have an effective system in place to test staff and 5 residents (R68, R48, R61, R23, R60) for COVID-19 during a facility outbreak. The facility failed to ensure COVID negative residents were not exposed to 3 residents (R68, R4, R51) who were COVID positive. These failures resulted in a facility outbreak of COVID-19 which, as of 11/13/23, included twenty-nine positive residents and sixteen positive staff. These failures have the potential to affect all 68 residents residing in the facility. The findings include: The facility CMS-671 dated 11/13/23 shows there are 68 residents residing in the facility. 1.…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-16 · tag F0692 — failed to prevent malnutrition and dehydration — pattern
    Provide 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 put interventions in place for a resident with significant weight loss. The facility also failed to provide ordered nutritional supplements for residents at risk for weight loss. This applies to 3 of 3 resident (R72, R39 and R46) reviewed for weight loss in the sample of 22. The findings include: 1. R72's Minimum Data Set Assessment of 9/24/23 shows that R72 was admitted to the facility on [DATE] with diagnoses including Renal Insufficiency, Neurogenic Bladder and Paraplegia. R72's Weights and Vitals Summary printed on 11/16/23 shows R72's admission weight on 9/18/23 as 139 lbs. (pounds). On 10/26/23 R72's weight was recorded as 128 lbs. (7.91% weight loss in 38 days). R72's Nutrition/Dietary Note written by V13 and dated 10/11/23 states, Increased protein needs related to wound healing as evidenced by stage 2 pressure injury to sacrum. Continue to follow with RD (Registered Dietician) available for consult PRN. The next Nutrition/Dietary…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-16 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a resident had a care plan to address pain for 1 of 22 residents (R44) reviewed for the development and implementation of a comprehensive care plan in the sample of 22. The findings include: R44's face sheet printed on 11/15/23 showed she was admitted on [DATE] with diagnoses to include, but not limited to, left knee osteoarthritis, cellulitis of left lower limb, pain in right shoulder, and pain in left shoulder. R44's physicians order sheet printed on 11/15/23 showed Acetaminophen-Codeine 300-30mg (milligrams) one tab by mouth two times a day for osteoarthritis, diclofenac sodium external gel 1% apply to skin topically as needed for pain control 4 times a day as needed, Lidocaine pain relieving patch 4% apply to skin topically in the morning for pain control and remove per schedule. R44's Minimum Data Set (MDS) dated [DATE] showed R44 as moderately cognitive impaired. Bed mobility requires limited assistance of one staff, transfers…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-16 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to remove a resident's facial hair and failed to provide set up assistance for meals for 2 of 22 residents (R17, R70) reviewed for activities of daily living in the sample of 22. The findings include: 1. On 11/13/23 at 9:52 AM, R17 was sitting up in her wheelchair. R17 had a mustache and facial hair on her chin and neck. R17 stated I don't like this (and rubbed her chin), and I don't like a mustache either. On 11/14/23 at 8:40 AM, R17 was in her room sitting at the bedside, eating breakfast. R17's facial hair and mustache remained. V8 (Certified Nursing Assistant/CNA) said R17 needs help with activities of daily living. V8 said R17 is supposed to get her face shaved during showers. V8 looked at R17 and stated They must not have done it with her shower over the weekend. R17 doesn't like the hair on her face. I will get the electric razor and take care of it. R17's Minimum Data Set, dated [DATE] shows R17 needs extensive assist of one person…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-16 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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 the catheter tubing for an indwelling urinary catheter was kept below the level of the bladder for 1 of 2 residents (R65) reviewed for urinary catheters in the sample of 22. The findings include: R65's Face Sheet printed on 11/14/23 showed he was admitted on [DATE] with diagnoses to include, but not limited to, retention of urine, hypertension, low back pain, and benign prostatic hyperplasia with lower urinary tract symptoms. R65's Physicians order sheet printed on 11/14/23 showed Foley (indwelling urinary catheter) catheter care every shift, monitor urine output via Foley every shift. R65's Minimum Data Set (MDS) dated [DATE] shows R65 is cognitively intact, bed mobility required limited assistance, transfer and toileting required supervision with one-person physical assist for all three. The assessment shows R65 has an indwelling catheter. R65's care plan printed 11/14/23 showed catheter care every shift and as needed. On 11/13/23…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-16 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop 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 ensure all residents were offered and/or received a pneumococcal immunization for 1 of 5 residents (R51) reviewed for immunizations in the sample of 22. The findings include: R51's admission Record dated 11/16/23 shows she was originally admitted to the facility on [DATE] and is [AGE] years of age. R51's Immunization Report dated 11/16/23 shows she last received a Pneumococcal Conjugate Vaccine (PCV13) on 3/23/22. Per current Centers for Disease Control and Prevention (CDC) guidelines, R51 was eligible and recommended for a Pneumococcal Vaccine (PCV20) one year after receiving the PCV13. On 11/14/23 at 2:54 PM, V2 (Director of Nursing/Infection Preventionist) said a resident's vaccination status is assessed on admission and annually. V2 said they offer the Pneumococcal 20 vaccination (PCV20). V2 said she just started reviewing residents' Pneumococcal status. The facility's Influenza and Pneumococcal Immunizations Policy (effective 11/28/12) shows each…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-09-12 · tag F0847 — widespread
    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record reviews, the facility's most recent arbitration agreements failed to include language that stated signing the agreement was not a condition/requirement to admission or receiving care at the facility. The facility also failed to update previously signed arbitration agreements which did not include language that: 1. The arbitration agreement could be rescinded in 30 days. 2. An arbitrator and meeting location would be mutually decided between parties. This applies to all 70 residents residing in the facility. The findings include: Facility Long-Term Care Facility Application for Medicare and Medicaid form, dated September 9, 2024, shows the facility census was 70 residents. On September 10, 2024 at 9:54 AM, V12 (Admissions Coordinator) stated the arbitration agreement is offered to every resident upon admission to the facility as a part of the admission contract. On September 10, 2024 at 9:57 AM, V1 (Acting Administrator) stated the facility arbitration agreement was imbedded in the facility admission contract. V1 stated the facility updated their…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$44,709 in federal fines across 6 penalties. 1 Medicare payment denial on record.

  • $32,445 — penalty dated 2023-11-16
  • $2,797 — penalty dated 2023-11-13
  • $2,447 — penalty dated 2023-11-06
  • $2,098 — penalty dated 2023-10-30
  • $1,748 — penalty dated 2023-10-23
  • $3,174 — penalty dated 2023-10-02
  • Medicare payment denial — starting 2023-12-14 for 22 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleShareSince
CITADEL OPCO HOLDING, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST50%since 07/01/2021
GLAT, DAVIDIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST20%since 07/01/2021
SILVER, MOSHEIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST20%since 07/01/2021
GRAF, MARCELLAIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 07/01/2021

CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner 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.

$8.5M
Net patient revenuemost recent cost report
-8.8%
Operating marginrevenue minus expenses
$1.2M
Related-party expense13% of expenses
Who pays — share of resident-days
Medicaid 16%Medicare 11%Other / private 73%

This home reported $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$346per resident / day
operating cost
$10,533per month
≈ monthly operating cost
$318per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Illinois
$8,304/mo
Nursing home (semi-private)
$9,216/mo
Nursing home (private)
$6,219/mo
Assisted living

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 145004. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-04, 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.

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