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Bella Terra Elmhurst

420 West Butterfield Road, Elmhurst, IL 60126 · For profit - Corporation · 142 certified beds · (630) 832-2300 Medicare & Medicaid certified

Call the home — (630) 832-2300 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

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)
  • no federal fines or payment denials on record
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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 4 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
360 W Butterfield Rd · (630) 523-9161 · Call to confirm hours
Pharmacy
155 E Brush Hill Rd · (630) 833-3724 · Call to confirm hours
Grocery
1 Tower Ln · (630) 560-0980 · Call to confirm hours
Park
363 Commonwealth Ln · (630) 390-9480 · Typically dawn to dusk
Place of worship

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 4 of 5
Long-stay residentspeople who live here 5 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 held steady at 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

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 increased14.5%13.4%15.4%typical
Long-stay residents who lose too much weight7.4%6.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.9%0.9%better
Long-stay residents with a urinary tract infection0.5%1.5%2.0%better
Long-stay residents with depressive symptoms86.5%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 injury2.0%3.1%3.3%better
Long-stay residents whose ability to walk worsened12.0%14.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication10.1%18.3%18.9%better
Long-stay residents given the seasonal flu vaccine93.8%91.8%95.3%typical
Long-stay residents with pressure ulcers6.1%4.8%4.7%worse
Long-stay residents with worsening bladder/bowel control21.8%20.6%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table8.3%21.7%17.1%better
Short-stay residents who newly got an antipsychotic medication1.5%2.2%1.4%typical
Short-stay residents given the seasonal flu vaccine65.7%63.1%79.4%worse
Short-stay residents rehospitalized after admission21.2%26.1%22.6%typical
Short-stay residents with an outpatient ER visit18.1%13.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.552.021.67typical
Long-stay outpatient ER visits per 1,000 resident days1.642.221.80typical

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.

57.2% 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 424 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

57.2%U.S. median 51.5%
Got home and stayed home
10.2%U.S. median 10.7%
Went back to hospital
58.7%U.S. median 56.6%
Met the expected recovery
0.62U.S. median 0.31
Therapy hours / resident / day
0.32hours / resident / day
Physical therapy
0.24hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 58.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 172 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 0.62 therapist hours per resident per day in 2026Q1 — more than 89% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 19% 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 SNF57.2%CMS range 51.7–61.851.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.2%CMS range 8.1–12.810.7%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 discharge58.7%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 discharge67.4%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 discharge61.6%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 identified99.1%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 setting97.0%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 discharge98.9%98.7%Oct 2024–Sep 2025CMS 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 stay0.9%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 worsened1.8%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 hospitalization7.8%CMS range 5.6–10.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.101.02Oct 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

0.98
RN hours/ resident / day
0.89
LPN hours/ resident / day
2.11
Aide hours/ resident / day
3.98
Total nurse hours/ resident / day
0.99
RN hoursweekends
49.2%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 142 beds and averages 101.5 residents a day — about 71% occupied, or roughly 40 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 3.98 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.98 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.11 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 4.03 hrs/resident/day on weekends vs 3.96 on weekdays — about the same on weekends as weekdays. RN hours go from 0.98 to 0.99 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 49% 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

7
deficiencies at the latest standard inspection (2024-03-14)
3
at the previous standard inspection (2023-06-09)

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.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

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.

29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.

  • Actual harm · Gcited before2024-12-30 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 assess and monitor a resident who had no recorded bowel movement for eight consecutive days who was experiencing abdominal discomfort. This failure resulted in R1 having acute rectal bleeding, requiring hospitalization for a blood transfusion and emergency intravenous medication administration to reverse the effects of her blood thinner. R1 also required the insertion of a rectal tube for the management of her fecal impaction. This applies to 1 out of 3 (R1) residents reviewed for constipation. The findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted on [DATE] with multiple diagnoses including dementia, psychosis, severe protein caloric malnutrition, anxiety, depression, diabetes type 2, hypertension, and hyperlipidemia. R1's MDS (Minimum Data Set) dated 9/17/2024 showed R1 was moderately cognitively impaired. The MDS continued to show R1 was always incontinent of bowel and required substantial to maximal staff assistance with…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-04 · 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 observations, interviews, and record reviews the facility failed to provide feeding assistance to dependent residents. This failure applies to 2 of 7 (R8, R12) residents reviewed for activities of daily living. Findings Include: 1. R12 is a is an [AGE] year-old female with diagnoses of history of Dementia, Major Depressive Disorder, Partial Paralysis due to Stroke, Dysphagia, Anemia, Seizures, and COPD who was admitted to the facility 01/19/2020. R12's Current Physician Orders include an active order effective 03/19/2024 for recommendation for one-to-one feeding assistance during all meals to ensure safety during oral intake per the most recent treatment course and active orders effective 10/22/2024 and 10/29/2024 for one-to-one feeding assistance with strict adherence to precautions. R12's current nutritional and dietary care plans initiated August 2021, July 2023, and March 2024 documents she requires a puree texture diet due to dysphagia; she is at risk for compromised nutritional status and…

    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 before2024-12-30 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to consult with a resident's physician when the resident had unrelieved acute gastrointestinal symptoms for 24 hours. This failure resulted in a resident calling the emergency paramedics herself for transfer to the hospital, and R6 was hospitalized for treatment of sepsis (a life-threatening complication of an infection) related to acute enterocolitis and aspiration pneumonia. This applies to 1 out of 3 (R6) residents reviewed for change in condition. The findings include: R6's EMR (Electronic Medical Record) showed R6 had multiple diagnoses, including gastro-esophageal reflux disease, irritable bowel syndrome, emphysema, congestive heart failure, and chronic obstructive pulmonary disease. R6's comprehensive care plan (initiated 2/4/2023) showed R6 was at risk for alteration in her gastrointestinal status. R6's care plan interventions included Give medications as ordered. Monitor/document side effects and effectiveness and Notify MD (medical doctor) of significant abnormalities .abdominal pain, diarrhea/constipation. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-25 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow its policy to immediately consult with a resident's physician and notify a resident's representative when a resident had a change in condition requiring resident to be transferred to the hospital. This applies to 2 of 6 residents (R1 and R2) reviewed for change in condition. The finding includes: 1. R2's EMR (Electronic Medical Record) showed R2 was admitted to the facility on [DATE] with multiple diagnoses including an encounter following surgery for a cardiac pacemaker, chronic atrial fibrillation, heart failure, pulmonary embolism, cerebrovascular disease, obstructive sleep apnea, and disorders of lungs. The EMR showed R2 was transferred to the hospital on 4/17/2024. R2's MDS (Minimum Data Set) dated 4/1/2024 shows R2 was cognitively intact and required staff assistance with her activities of daily living. On 4/24/2024 at 8:50 AM, V16 (Agency Registered Nurse/RN) stated she took care of R2 overnight on 4/16/2024. V16 stated R2 kept calling…

    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 · D2024-04-25 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to respond after being notified of a concern of missing items. This applies to 1 of 6 residents (R1) reviewed for grievances. The findings include: On 4/19/2024 at 12:50 PM, V4 (R1's daughter) stated she notified the facility on 1/7/2024 that R1's cell phone was missing. V4 stated she tried to use her phone locater application to locate the phone and V6 (Guest Service Director) and V13 (Medical Records Staff) tried to assist her, but the phone was not found. V4 stated on 1/11/2024 she asked the nurse on duty for R1's hearing aids that were stored in the nurse's medication cart for safekeeping, but they were not located. V4 stated she emailed V6 on 1/16/2024 for an update on the missing items and on 1/19/2024 V6 informed he would inform V1 (Administrator). V4 stated she continued to email V1 and V6 weekly, and on 2/16/2024 the facility told her they would reimburse her for the cell phone balance, but then they stopped responding to her emails. V4 stated she last emailed the facility on 3/26/2024 and became frustrated because…

    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 before2024-04-25 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 administer the ordered oxygen to a resident complaining of shortness of breath. This applies to 1 of 1 (R2) resident reviewed for respiratory care. The finding includes: R2's EMR (Electronic Medical Record) showed R2 was admitted to the facility on [DATE] with multiple diagnoses including an encounter following surgery for a cardiac pacemaker, chronic atrial fibrillation, heart failure, pulmonary embolism, cerebrovascular disease, obstructive sleep apnea, and disorders of lungs. The EMR showed R2 was transferred to the hospital on 4/17/2024. R2's MDS (Minimum Data Set) dated 4/1/2024 shows R2 was cognitively intact and required staff assistance with her activities of daily living. On 4/24/2024 at 9:00 AM, R2 was interviewed over the phone. R2 stated on 4/16/2024 around 7 PM she started to feel short of breath and needed oxygen. R2 stated V16 (Agency Registered Nurse/RN) told her she would give her oxygen but then told her something was missing. R2…

    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 · Ecited before2024-03-14 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    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

    Based on observation, interview, and record review, the facility failed to provide perineal and indwelling catheter care in a manner that would prevent urinary tract infection (UTI) and failed to ensure that an indwelling catheter is secured to the resident. This applies to 4 of 4 residents (R21, R63, R93, and R102) reviewed for catheter and bowel and bladder care in the sample of 22. The findings include: 1. On March 12, 2024, at 4:38 PM, V15 (Wound Care Nurse) provided wound care to R102. R102 had an indwelling urinary catheter. The catheter tube was not secured to R102, it was pulling whenever R102 turned or moved during wound care. 2. On March 13, 2024, at 10:45 AM, V16 (Certified Nursing Assistant/CNA) rendered peri-care to R21 who had an indwelling urinary catheter tube. V16 cleaned R21's pubic area, penis, and groins, however V16 did not clean the scrotum. V16 proceeded to clean the buttocks and rectum. After V16 cleaned the back perineum, she went back to the frontal perineum to clean the catheter tube while wearing the same soiled gloves. 3. On March 13, 2024, at 11:03 AM,…

    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 · Ecited before2024-03-14 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to follow standard infection control practices related to hand hygiene and gloving during provisions of peri-care and wound care. This applies to 4 of 22 residents (R21, R63, R93, R102) reviewed for infection control in the sample of 22. The findings include: 1. On March 12, 2024, at 4:26 PM, V15 (Wound Care Nurse) provided wound care to R102 who had Moisture Associated Skin Disorder (MASD) to abdomen and stage 3 pressure ulcer to sacrum. During the wound care procedure, V15 kept changing her gloves in between tasks without performing hand hygiene. 2. On March 13, 2024, at 10:45 AM, V16 (Certified Nursing Assistant/CNA) rendered peri-care to R21. V16 cleaned R21 from front to back to front, V16 applied clean incontinence brief and repositioned R21 while wearing the same soiled gloves. Afterwards, V21 changed her gloves without performing hand hygiene, and applied barrier cream. V16 proceeded to straighten R21's gown and bed linen while still wearing the same gloves. 3. On March 13, 2024, at 11:03 AM, V13 (CNA)…

    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 before2024-03-14 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 failed to hold a care plan conference with the resident. This applies to 1 of 1 resident (R11) reviewed for care planning in the sample of 22. The findings include: R11's EMR (Electronic Medical record) showed R11 was admitted to the facility on [DATE]. On March 11, 2024, at 11:36 AM, R11 stated she has never had or been offered to participate in a care plan conference. R11 stated she would like a care plan conference to know what the plan of care was and what was going on. R11 stated she wants to be transferred to another facility and was wondering how her application for Medicaid was going. On March 12, 2024, at 1:25 PM, V17 (Social Worker Director) stated care plan conferences are normally set up within 24 to 72 hours of admission and quarterly. V17 stated there was a multi-disciplinary care conference form opened by V18 (MDS Coordinator) on January 30, 2024, in R11's electronic medical record, but it was empty. V17 and V18 stated neither of them have…

    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 before2024-03-14 · 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

    Based on observation, interview and record review, the facility failed to provide grooming to a resident that is dependent on staff for care. This applies to 1 of 3 residents (R40) reviewed for ADL (activities of daily living) care in the sample of 22. The findings include: R40's face sheet included diagnoses of hemiplegia, unspecified affecting right nondominant side, cerebrovascular disease, spinal stenosis, cervical region. R40's Quarterly MDS (minimum data set) dated December 13, 2023, showed that R40 was cognitively intact and was depended on staff for personal hygiene. On March 11, 2024, at 11:35 AM, R40 was lying in bed and noted to have fingernails that were very long (about an inch) with some of them jagged and with extensive blackish substance underneath nail beds. R40 also had extensive thick black color facial hair on entire lower chin that was also about an inch long. R40 stated that she would like to have her fingernails cut and cleaned and facial hair removed. R40's son (V7) who was present agreed with the same. V5 (Licensed Practical Nurse) and other staff were…

    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 · D2024-03-14 · 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 follow manufacturer's instructions for a pressure relieving mattress. This applies to 1 of 6 residents (R4) reviewed for pressure ulcers in the sample of 22. The findings include: R4's EMR (electronic medical records) included diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, contracture left hand, contracture right hand, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R4's Annual MDS (minimum data set) dated January 23, 2024, showed that R4 was severely impaired in cognition. Facility matrix showed that R4 has an acquired pressure ulcer stage 3. Wound evaluation dated March 4, 2024, also showed that R4 acquired an in-house pressure ulcer Stage 3 on left buttocks. R4's weights and vitals section in EMR showed that R4 was 116 pounds on March 4, 2024. On March 11, 2024, at 11:16 AM, R4 was lying in bed that had a pressure relieving mattress. The control knob was switched ON and…

    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
Show the remaining 18 citations
  • Potential for harm · D2024-03-14 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    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 provide lunch meal and assistance with feeding to a resident with weight loss. This applies to 1 of 5 residents (R40) reviewed for nutrition in the sample of 22. The findings include: R40's EMR (electronic medical records) included diagnoses of hemiplegia, unspecified affecting right nondominant side, unspecified protein-calorie malnutrition, non-pressure chronic ulcer of other part of right lower leg with other specified severity, cervical disc disorder with radiculopathy, unspecified cervical region, and anorexia. R40's Quarterly Minimum Data Set, dated [DATE], showed that R40 was cognitively intact and required partial moderate assistance in eating. R40's diet order on EMR showed Regular diet, Regular texture, thin liquids consistency, 1:1 feeding assistance required. R40's care plan created August 30, 2023, included that R40 with compromised nutritional status due to diagnoses of hemiplegia, anorexia, and requires assistance with…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-14 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their policy to attempt a gradual dose reduction for a resident on psychotropic medications. This applies to 1 of 5 residents (R14) reviewed for unnecessary medications in the sample of 22. The findings include: R14's EMR (Electronic Medical Record) showed R14 was 94 years-old and was admitted to the facility on [DATE], with multiple diagnoses including major depressive disorder, anxiety disorder, insomnia, and chronic kidney disease. R14's MDS (Minimum Data Set) dated December 28, 2023, showed R14 had severe cognitive impairment. R14's Order Summary Report dated March 13, 2024, showed the following medications for R14: Alprazolam (anti-anxiety/sedative) oral tablet 1 mg (milligram), give one tablet by mouth at bedtime for anxiety, order started on December 7, 2022. Amitriptyline (antidepressant) oral tablet 25 mg, give 25 mg by mouth at bedtime for sleep, order started on December 9, 2022. Mirtazapine (antidepressant) tablet 15…

    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 · Ecited before2023-12-28 · tag F0657 — failed to keep the care plan current — pattern
    Develop 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 failed to hold care plan conferences with residents and their representatives and failed to invite residents and their representatives to participate in the care planning process. This applies to 5 of 5 residents (R1, R3, R5, R7, and R8) reviewed for policy and procedures in the sample of 8. The findings include: 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility in March 2020 with multiple diagnoses including, aphasia following cerebral infarction, chronic kidney disease, myocardial infarction, pulmonary embolism, hypertension, heart failure, atrial fibrillation, dementia, and chronic respiratory failure. The EMR continues to show R1 was sent to the local hospital on December 16, 2023, due to low blood pressure and returned to the facility on December 19, 2023. R1's MDS (Minimum Data Set) dated November 4, 2023, shows R1 has severe cognitive impairment, is able to eat with setup or clean-up assistance, requires supervision for oral…

    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 before2023-12-28 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to follow their policy to immediately notify a resident's representative when a resident had a change in condition requiring transfer to the local hospital. This applies to 1 of 3 residents (R1) reviewed for change in condition notification in the sample of 8. The findings include: The EMR (Electronic Medical Record) shows R1 was admitted to the facility in March 2020 with multiple diagnoses including, aphasia following cerebral infarction, chronic kidney disease, myocardial infarction, pulmonary embolism, hypertension, heart failure, atrial fibrillation, dementia, and chronic respiratory failure. The EMR continues to show R1 was sent to the local hospital on December 16, 2023, due to low blood pressure and returned to the facility on December 19, 2023. R1's MDS (Minimum Data Set) dated November 4, 2023, shows R1 has severe cognitive impairment, is able to eat with setup or clean-up assistance, requires supervision for oral hygiene, and partial/moderate assistance with all other ADLs (Activities of Daily Living). R1 is always…

    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 before2023-12-28 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 follow physician orders to weigh residents daily, and to check systolic blood pressure readings prior to administering cardiac/blood pressure medications. This applies to 3 of 3 residents (R1, R4, and R7) reviewed for improper nursing care in the sample of 8. The findings include: 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility in March 2020 with multiple diagnoses including, aphasia following cerebral infarction, chronic kidney disease, myocardial infarction, pulmonary embolism, hypertension, heart failure, atrial fibrillation, dementia, and chronic respiratory failure. The EMR continues to show R1 was sent to the local hospital on December 16, 2023, due to low blood pressure and returned to the facility on December 19, 2023. R1's MDS (Minimum Data Set) dated November 4, 2023, shows R1 has severe cognitive impairment, is able to eat with setup or clean-up assistance, requires supervision for oral hygiene, and…

    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 · D2023-09-22 · tag F0825 — isolated
    Provide or get specialized rehabilitative services as required for a resident.
    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 physical therapy (PT) services to a resident with ordered rehab services. This applies to 1 of 3 residents (R1) reviewed for physical therapy. The findings include: On 9/22/23 at 9:46 AM, R1 said he started getting physical therapy a few days ago. R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility with diagnoses including fracture of vertebrae, psychosis, dementia, difficulty in walking, age-related physical debility, lack of coordination, fall, and dysphagia. R1's MDS (Minimum Data Set) dated 8/2/23 shows R1 was cognitively intact and required supervision for eating, and extensive assistance for bed mobility, transferring, dressing, toileting, and personal hygiene. On 9/22/23 at 7:45 AM, V4 (Family Member) said R1 went to the neurologist's office on 9/13/23 and got an order for physical therapy. V4 said she gave the nurse the paperwork with the orders and the nurse forgot about it and did not tell anybody about it. V4 said R1 should have started physical therapy on 9/13/23. V4 said R1 only…

    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 · Ecited before2023-06-09 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    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 personal hygiene assistance to meet the needs of residents dependent on staff. This applies to 4 of 8 residents (R7, R27, R56, R61) reviewed for ADLs (Activities of Daily Living) in a sample of 27 residents. The findings include: 1. R27's MDS dated [DATE], shows R27 requires extensive assistance with two persons for personal hygiene. On June 6, 2023, at 11:11 AM, R27 said she has a problem getting her baths every Monday and Friday as scheduled. R27 said her last bath was four days ago (Friday), and by day six (Thursday) she gets a little grungy. R27 said she did not get her bath on Monday. On June 7, 2023, at 11:49 AM, R27 was observed with her hair starting to look greasy. R27 said she did not get any bath yesterday or today. R27's Care Plan dated May 11, 2023, shows she requires extensive assistance with ADLs including personal hygiene related to generalized weakness and poor activity tolerance. Intervention includes to assist…

    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 · Ecited before2023-06-09 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to properly secure medications; sign controlled substances count form and resident's narcotic sheet; have two nurses sign off on the narcotic sheet when wasting narcotic medication; remove expired medication and double-lock narcotic medication. This applies to 15 of 15 residents (R16, R25, R28, R29, R46, R50, R53, R54, R56, R58, R60, R63, R66, R71, R295) reviewed for medications. The findings include: On June 6, 2023, at 10:51 AM, V3 (RN/Registered Nurse) identified the residents who have medications in her medication cart. The following observations were made: 1. R46's medication card with Lacosamide 100 MG (Milligrams) had 11 tablets. It was compared to R46's controlled drug administration record which documents: Lacosamide 100 MG: Give 1 tablet by mouth twice daily. The form showed the medication card contained 12 tablets. V3 was questioned about the discrepancy. V3 replied, I wasted it (Lacosamide) with the other nurse (V5-RN) and put it…

    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 · Ecited before2023-06-09 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to follow infection control procedures during medication administration, equipment cleaning, incontinence care, and while providing direct care of residents under EBP (Enhanced Barrier Precautions). This applies to 7 of 8 residents (R23, R31, R54, R59, R67, R95, R346) reviewed for infection control in a sample of 27. Findings include: 1. On June 6, 2023, at 11:32 AM, V3 (RN/Registered Nurse) performed a blood glucose check on R54 in her room with a glucometer. V3 then took the glucometer to her medication cart. V3 removed her gloves and put on new gloves without performing hand hygiene and proceeded to sanitize the glucometer with bleach wipes. Facility's policy titled Glucose Meter Cleaning (July 28, 2022) documents: Procedures: 1. Wash hands thoroughly with soap and water or hand sanitizer before and after the procedure. 2. Wear clean gloves. 3. Place the equipment on a clean surface. 4. Clean and disinfect glucose meter with bleach wipes before after each use. 2. On June 7, 2023, at 8:03 AM, V4 (Agency 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-05-05 · tag F0888 — widespread
    Ensure staff are vaccinated for COVID-19
    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 all staff were fully vaccinated for COVID-19. This has the potential to affect all 87 residents residing in the facility. The findings include: The Resident Census and Conditions of Residents form dated May 02, 2022, showed the facility census as 87 residents. Facility undated Covid-19 Staff Vaccination Status for Providers updated and given on 5/4/22 at 10:20 AM, included 11 staff (V8-V18) were scheduled to receive the Booster dose. The same document showed that V9-V12 and V14-V17 were direct care staff. Vaccination records for V8-V18 showed that they only received the first and second COVID-19 vaccine doses and are currently pending to receive booster dose. The Staff Formulas calculations showed that 87.8% of current staff are vaccinated. On 5/3/22 at 1:37 PM and 4:36 PM V2 (Director of Nursing) stated that the facility census is 87 residents and around 94% of staff are compliant with the COVID-19 vaccination. V2 stated that V1 (Administrator) enters information in NHSN (National healthcare safety…

    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 · Ecited before2022-05-05 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    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 4. R26's face sheet showed that R26 is 49 years-old with multiple medical diagnoses which includes: Polyneuropathy, Fibromyalgia, Spinal Stenosis, Ataxia, and lack of coordination. R26's Minimum Data Set (MDS) dated [DATE] indicates that R26 is alert and oriented and requires extensive assistance with grooming/hygiene. R26's Care Plan showed that R26 is alert and oriented and requires assistance with Activities of Daily Living (ADL) care such as bed mobility, transfer, dressing, walking, personal hygiene, and toileting. On 5/03/22 at 9:38 AM, R26 was resting in bed displaying overgrown facial hair in the cheeks, upper lip, chin and below chin/upper neck. R26 stated that she would like it shaved. She appeared anxious and tearful. On 5/03/22 at 12:29 PM, V25 (CNA) stated that R26 wants her family to shave for her. R26 responded that she does not mind staff shaving her as long as the staff don't cut her (or injure her). V25 and V29 (CNA) shaved R26's facial hair on 5/03/22 at 12:33 PM, R26 stated that she felt…

    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 · Ecited before2022-05-05 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    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

    Based on observation, interview, and record review, the facility failed to provide incontinence care in a manner that would prevent Urinary Tract Infection (UTI) and failed to ensure that an indwelling urinary catheter tubing is anchored/secured to prevent from pulling. This applies to 4 of 6 residents (R26, R47, R124, R125) reviewed for incontinence and catheter care in the sample of 19. The findings include: 1. R26's face sheet showed that R26 is 49 years-old with multiple medical diagnoses which includes: Polyneuropathy, Fibromyalgia, Spinal Stenosis, Ataxia, and lack of coordination. On 5/03/22 at 12:37 PM, V25 and V29 (Both Certified Nursing Assistant/CNA), rendered incontinence care to R26 who was wet with urine and had a bowel movement. V25 ran the wet wipes from R26's pubic area down to the outer labia. However, V25 did not separate labial folds and did not attempt to reached inner groins to clean the crevices. 2. R 125's face sheet showed that R125 is 90 years-old with multiple medical diagnoses which include Acute Kidney Failure, Stage 3 Chronic Kidney Disease, Dementia,…

    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 · Ecited before2022-05-05 · 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 follow manufacturer's and/or pharmacy recommendation with regards to medication storage and labeling and failed to ensure that a narcotic medication is not taped in the blister pack. This applies to 5 of 6 residents (R34, R39, R52, R68, R126 ) reviewed for medication storage and labeling. The findings include: On 5/04/22 at 10:54 AM, medication cart inspection was conducted on the first-floor unit of the facility with V40 (Nurse), and the following were observed: 1. R34's Humalog 100 units/ml was unopened and stored in the cart. The instruction label of this insulin's container indicates that this medication should be kept in the refrigerator while unopen. 2. R68's Novolog 100 units/ml was open and not dated. Facility's Policy and procedure for Medication Labeling indicates: - Insulin vials are to be discarded within 28 days after opening except for Levemir Insulin which are to be discarded 42 days after opening. 3. R126's Victoza 18mg/3ml was open and not dated. According to Victoza's manufacturer's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-05-05 · tag F0880 — failed to prevent and control infections — pattern
    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 standard infection practices with regards to hand hygiene and gloving during provisions of care, failed to don a gown when entering an isolation room, and failed to ensure that there is a posted sign on a door for transmission-based precaution. This applies to 5 of the 19 (R26, R47, R125, R329, R330) residents reviewed for infection control in the sample of 19. The findings include: 1. On 5/03/22 at 12:37 PM, V25 and V29 (Both Certified Nursing assistants/ CNA) rendered incontinence care to R26 who was wet with urine and had a bowel movement. V25 wiped R26's frontal perineum, then she (V25) changed her gloves without hand hygiene prior to cleaning the rectal and buttocks area. V25 used a spray cleanser while cleaning the fecal matter from R26's rectal and buttocks area. V25 was observed going back and forth cleaning the buttocks and touching/holding and using the spray cleanser to R26 using same gloves. After completing 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-05-05 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 failed to review and update the care plan with interventions for pain management after a resident had a fall with a fracture. This applies to 1 of 2 residents (R14) reviewed for pain medication. The findings include: According to the Electronic Health Record (EHR) R14 had diagnoses including Osteoporosis with current Right Humerus fracture, Chronic Kidney Disease, Diabetes, Peripheral Vascular Disease, Hemiplegia and Hemiparesis, Gastroesophageal Reflux Disease, low back pain, Atherosclerotic Heart Disease, Convulsions, Depressive Disorder, Aphasia, Vascular Dementia, absence of left foot, and Cerebral Infarction. The Minimum Data Set (MDS) dated [DATE] showed R14 needed extensive assistance of two people for bed mobility, transfers, dressing, eating, hygiene, and toilet use. The MDS showed R14's cognition was severely impaired. The Care Plan showed R14 was at risk for pain related to low back pain, Diabetes, and Peripheral Vascular Disease with interventions to…

    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 · D2022-05-05 · 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, interview and record review, the facility failed to follow guidance of no straws for residents that had an order for the same. This applies to 2 of 3 residents (R123 and R223) for order of no straws during review of hydration. The findings include: 1. R223's EMR (electronic medical records) including diagnoses of Dysphagia, Oropharyngeal Phase, Cognitive Communication Deficit, unspecified Dementia with behavioral disturbance, Attention and Concentration Deficit, Severe Protein-Calorie Malnutrition, Primary open-angle Glaucoma, Bilateral Moderate Stage. R223's diet order in the EMR included CCHO (Consistent Carbohydrates) Mechanical Soft Thin Liquids Consistency, NO STRAWS order date 4/28/2022 18:43 (status active). On 05/02/2022 at 12:24PM, R223 was visited in his room and noted to have two 16 oz/ounce disposable cups of water at bedside table with a straw in each cup. R223's spouse, V7, who was present in the room stated He's not supposed to drink with the straw. The hospital stated he is…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-05-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    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 provide assistance to a resident with obstructive Sleep Apnea in using a Sleep Apnea machine. This applies to 1 of 1 residents (R173) reviewed for respiratory equipment in a sample of 19. The findings include: According to the Electronic Health Record (EHR) R173 has diagnoses including Pre-Diabetes, Duodenal Ulcer, Morbid (severe) Obesity, Hyperlipidemia, Bilateral Cataract, Rheumatoid Arthritis, Hypertension, history of COVID-19, Congestive Heart Failure, Acute Respiratory Failure with Hypoxia and Hypercapnia, Obstructive Sleep Apnea, Anxiety Disorder, Osteoarthritis, Gastro-Esophageal Reflux Disease, dependence on supplemental oxygen, and Cor Pulmonale. The Minimum Data Set (MDS) dated [DATE] showed R173 needed extensive assistance of one person for bed mobility, transfers, dressing, and toilet use. The MDS showed R173's cognition was intact. The Physician Order Sheet (POS) shows an order dated 04/22/2022 for AVAPS (Average volume-assured pressure…

    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 · D2022-05-05 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary 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 interview and record review the facility failed to evaluate and justify the continued use of a narcotic pain medication. The facility also failed to assess a resident for Abnormal Involuntary Movements prior to starting a medication with a black box warning and failed to justify continued use of the medication longer than twelve weeks. This applies to 2 of 6 residents (R14 and R44) reviewed for unnecessary medication in a sample of 19. The findings include: 1. According to the Electronic Health Record (EHR) R14 had diagnoses including Osteoporosis with current Right Humerus Fracture, Chronic Kidney Disease, Diabetes, Peripheral Vascular Disease, Hemiplegia and Hemiparesis, Gastroesophageal Reflux Disease, low back pain, Atherosclerotic Heart Disease, Convulsions, Depressive Disorder, Aphasia, Vascular Dementia, absence of left foot, and Cerebral Infarction. The Minimum Data Set (MDS) dated [DATE] showed R14 needed extensive assistance of two people for bed mobility, transfers, dressing, eating, hygiene,…

    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

“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

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 →

RatingThis homeChain avg
Overall 4 of 52.9+1.1 vs chain
Health inspection 4 of 52.8+1.2 vs chain
Staffing 2 of 52.5-0.5 vs chain
Quality measures 4 of 53.3+0.7 vs chain
The other 88 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Avantara ArrowheadRapid City, SD 1 of 5Avantara Evergreen ParkEvergreen Park, IL 1 of 5Avantara MilbankMilbank, SD 1 of 5Avantara Saint CloudRapid City, SD 1 of 5Avantara WatertownWatertown, SD 1 of 5Emmetsburg Care CenterEmmetsburg, IA 1 of 5Grove Of Elmhurst, TheElmhurst, IL 1 of 5Harmony Cedar RapidsCedar Rapids, IA 1 of 5Harmony House Health Care CenterWaterloo, IA 1 of 5Harmony MarshalltownMarshalltown, IA 1 of 5Harmony WaterlooWaterloo, IA 1 of 5Harmony West Des MoinesWest Des Moines, IA 1 of 5Nexus at BerwynBerwyn, IL 1 of 5Northgate Care CenterWaukon, IA 1 of 5Park View Rehabilitation CenterSac City, IA 1 of 5Southfield Wellness CommunityWebster City, IA 1 of 5Warren Barr South LoopChicago, IL 2 of 5Avantara GrotonGroton, SD 2 of 5Avantara HuronHuron, SD 2 of 5Avantara Lincoln ParkChicago, IL 2 of 5Avantara Mountain ViewRapid City, SD 2 of 5Avantara Palos HeightsPalos Heights, IL 2 of 5Avantara PierrePierre, SD 2 of 5Avantara RedfieldRedfield, SD 2 of 5Bella Terra BloomingdaleBloomingdale, IL 2 of 5Bella Terra Morton GroveMorton Grove, IL 2 of 5Carlton At The Lake, TheChicago, IL 2 of 5Chalet Living & RehabChicago, IL 2 of 5Colonial Manor of ElmaElma, IA 2 of 5Hallmark Care CenterMount Vernon, IA 2 of 5Harmony DavenportDavenport, IA 2 of 5Harmony DubuqueDubuque, IA 2 of 5Harmony PalosPalos Heights, IL 2 of 5Harmony Utica RidgeDavenport, IA 2 of 5Heritage Care And Rehabilitation CenterMason City, IA 2 of 5Manor House Care CenterSigourney, IA 2 of 5Peterson Park Health Care CtrChicago, IL 3 of 5Avantara LibertyvilleLibertyville, IL 3 of 5Avantara NorthRapid City, SD 3 of 5Bloomfield Care CenterBloomfield, IA

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 / managerTypeRoleShareSince
DOROS GENERATION TRUST U/A/D 1/3/12Organization5% OR GREATER DIRECT OWNERSHIP INTEREST17%since 06/01/2021
GPN FAMILY TRUST U/A/D 4/28/08Organization5% OR GREATER DIRECT OWNERSHIP INTEREST17%since 06/01/2021
GARDEN, DANIELIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST8%since 06/01/2021
NINIO, MORDECHAYIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST59%since 06/01/2021
BROWN, TREMAINEIndividualW-2 MANAGING EMPLOYEEsince 06/01/2021
TBDMD IL, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 06/01/2021

3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$16.0M
Net patient revenuemost recent cost report
-1.9%
Operating marginrevenue minus expenses
$271K
Related-party expense2% of expenses
Who pays — share of resident-days
Medicaid 16%Medicare 22%Other / private 62%

This home reported $271K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$447per resident / day
operating cost
$13,589per month
≈ monthly operating cost
$439per 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 145711. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-03-14, 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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