Grove Of Elmhurst, The
127 West Diversey, Elmhurst, IL 60126 · For profit - Corporation · 180 certified beds · (630) 530-5225 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (50) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $143,281 in federal fines (most recent 2026-06-11)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- about 17% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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 1 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 11.1% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.9% | 6.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.1% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.4% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 94.4% | 54.2% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 3.6% | 0.1% | 0.1% | worse |
| Long-stay residents with falls causing major injury | 2.6% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 15.3% | 14.3% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 17.6% | 18.3% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 99.3% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 9.7% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 18.2% | 20.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 28.7% | 21.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 2.9% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 74.7% | 63.1% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 20.8% | 26.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 13.8% | 13.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.33 | 2.02 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.10 | 2.22 | 1.80 | worse |
‡ 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.
63.4% 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.
Met the expected recovery: 45.5% 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 22 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 0.09 therapist hours per resident per day in 2026Q1 — more than 5% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 63.4%CMS range 42.4–80.3 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.0%CMS range 6.4–15.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 45.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 50.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 50.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not 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 stay | 6.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.2% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.01 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 180 beds and averages 134.8 residents a day — about 75% occupied, or roughly 45 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 3.36 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.68 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.92 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 3.30 hrs/resident/day on weekends vs 3.39 on weekdays — 3% thinner on weekends. RN hours go from 0.67 to 0.71 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
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.
50 citations, most serious first. The 15 most serious are shown; the remaining 35 are one tap away and print in full.
- Immediate jeopardy · J2026-06-11 · tag F0678 — failed to provide CPR when needed — isolatedProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
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 its policy and perform AHA (American Heart Association) CPR (Cardiopulmonary Resuscitation).This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on 5/7/26 at 5:04 PM when the facility failed provide timely rescue breaths and placement of the available AED (Automatic External Defibrillator) on an unresponsive resident designated as full code.This applies to 82 of 83 residents (R1, R3-R83) reviewed for quality of care in the sample of 83.V1 (Administrator), V2 (Director of Nursing), and V36 (Corporate Consultant) were notified of the Immediate Jeopardy on 6/9/26 at 5:50 PM. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 6/9/26 at 8:57 PM, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training and plan implementation.The findings include:Facility Order Listing Report, printed 6/9/26, shows R3-R83 had physician orders for full…
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.
- Immediate jeopardy · Jcited before2024-05-09 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 protect the resident's right to be free from physical abuse by V3 (Agency CNA-Certified Nursing Assistant), when V3 punched R1 in the face and grabbed R1's lower arm. This applies to 1 of 4 residents (R1) reviewed for staff-to-resident abuse in the sample of 7. This failure resulted in R1 experiencing bruising on her face and lower arm and R1expericing a psychosocial impact. R1 stated she can still see V3's fist coming towards her face when she closes her eyes. The Immediate Jeopardy began on April 27, 2024, at 8:00 PM when V3 (Agency CNA) punched R1 in the face and grabbed R1's lower arm. V26 (Assistant Administrator), V25 (Vice President of Operations), and V19 (Regional Nurse Consultant) were notified of the Immediate Jeopardy on May 7, 2024, at 1:41 PM. The facility presented an abatement plan to remove the immediacy on May 7, 2024, at 2:16 PM, and the survey team accepted the abatement plan on May 7, 2024, at 2:59 PM. The surveyor…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2026-06-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide 1:1 supervision at a meal to a resident who had physician orders for 1:1 feeding assistance.This failure resulted in R1 consuming food during a meal while unsupervised and becoming unresponsive for 13 minutes before being assisted.This applies to 1 of 3 residents (R1) reviewed for meal supervision in a sample of 83.The findings include: Face sheet, dated 6/5/26, shows R1's diagnoses included Huntington's disease, dysphagia, chorea, personal history of sudden cardiac arrest, dementia, lack of coordination, signs/symptoms involving the musculoskeletal system, and abnormality of gait/mobility. Nurse practitioner progress notes, dated 4/24/26, shows R1 was at risk for aspiration and required aspiration precautions.POS (Physician Order Sheet), printed 6/5/26, shows R1 had an order dated 4/3/26 for a Mechanical Soft diet with 1:1 feeding assistance. The order shows R1 also had physician orders for swallowing precautions which included taking small bites, offering food at a slow rate, alternating liquids 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.
- Actual harm · Gcited before2025-05-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure a resident's wheelchair was in safe repair to prevent injuries. The failure resulted in R340 sustaining an L shaped laceration on her right lower leg when she bumped her right leg and scraped it on the uncapped right front wheel connector. R340 was sent to the hospital and received 11 sutures for the laceration on her right leg. This applies to 1 out of 1 (R340) resident reviewed for accidents in the sample of 33. The findings include: On 5/20/2025 at 10:36 AM, R340 was in her room with a soiled dressing on her right lower leg. R340 said on 5/18/2025 at around 5:00 AM, she was in the bathroom and when she was transferring from her wheelchair to the toilet, the skin on her right leg caught on the uncapped right front wheel connector of her wheelchair. She said she was bleeding so much that she was sent to the hospital and she has 11 stitches on her right leg. R340's Progress Notes from the Emergency Department of the local hospital dated 5/18/2025 documents R340 said she sustained laceration because her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-04-05 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to identify, report, assess, and obtain physician orders for new skin breakdown; failed to ensure treatment dressings were in place, soiled dressings were changed for residents with stage 3 and stage 4 pressure ulcers; and failed to implement pressure ulcer interventions. As a result of these failures, R41 had an unidentified right ischium wound with 25% necrotic tissue that was uncovered with no treatment; R24 had a right ischium wound with necrotic muscle tissue exposed with no treatment; and R18 had a right ischium wound with no treatment that increased in size from previous assessments. This applies to 5 of 5 residents (R9, R18, R24, R41, and R66) reviewed for pressure ulcers in a sample of 30. The findings include: 1. The EMR (Electronic Medical Record) showed R41 admitted to the facility on [DATE] with multiple diagnoses including multiple pressure ulcer stage, diabetes type 2, nutritional deficit, and tracheostomy dependent on a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-06-25 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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 ensure residents who required assistance with Activities of Daily Living (ADLs) received the necessary care and services to maintain personal hygiene, including oral care, nail care, and grooming.This applies to 5 of 9 residents (R42, R73, R89, R102, and R115) reviewed for ADL care in the sample of 31. The findings include: 1. R102's face sheet showed he was admitted to the facility with diagnoses that included epilepsy, dysphagia, insomnia, history of falling, anemia, gastro-esophageal reflux disease and other symptoms and signs involving the musculoskeletal system. R102's Minimum Data Set, dated [DATE] showed he was severely cognitively impaired and required substantial maximal assistance for personal hygiene. On June 22, 2026 at 1:39 PM, R102 was sitting in the dining room with an accumulation of flacking white substance covering all areas of resident's short stubby beard and mustache and including his side burns and forehead. There…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-08 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to respect residents' dignity by using cell phones during resident care. This applies to 3 of 3 resident (R1, R2, and R3) reviewed for resident rights in the sample of 6. The findings include:On 1/7/26 at 10:53 AM, V9 R1's Daughter stated, The CNAs (Certified Nursing Assistants) are on their phones all the time. V9 stated on one occasion she was talking to a CNA, the CNA had earbuds in, the CNA said hold on to the person she was talking to on her cell phone, reached into her pocket to pause the phone call before she could talk to V9. V9 said she has recently observed CNAs on their phone while providing care for her mother. On 1/7/26 at 10:53 AM, R1 stated, regarding staff being on their phones during resident care, I see it all the time. On 1/7/26 at 1:04 PM, V8 R3's Mother stated, I do see staff on their phones all the time. Yes, I have seen staff on their phones when providing care. I don't like it, it shouldn't happen. It is disrespectful. (R3 was nonverbal, not alert, and not oriented.) On 1/7/26 at 12:10 PM, R2 stated she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-08 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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 change a resident's feeding tube dressing as ordered. This applies to 1 of 3 residents (R1) reviewed for nursing care in the sample of 6. The findings include:R1's admission Record (Face Sheet) showed she was admitted to the facility on [DATE] with diagnoses to include but not limited to functional quadriplegia (severe disability of all four limbs); ventilator dependence, and heart failure. R1's Order Summary Report (Physician Order Sheet) showed an active order started on 12/4/24 to Cleanse enteral tube feeding site with normal saline and apply dry dressing every night shift. On 1/7/26 at 10:29 AM, R1 was supine in bed feeding herself a sweet roll. There was a foul odor that appeared to be coming from R1. The odor was not consistent with stool odor. On 1/7/26 at 11:30 AM, V15 Shift Coordinator / Certified Nursing Assistant (CNA) and V16 CNA entered R1's room to provide incontinence care. During incontinence care, it was requested that V15…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-08 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide incontinence care in a manner to prevent urinary tract infections (UTI). This applies to 1 of 3 residents (R1) reviewed for nursing care in the sample of 6. The findings include:R1's admission Record (Face Sheet) showed she was admitted to the facility on [DATE] with diagnoses to include but not limited to functional quadriplegia (severe disability of all four limbs); ventilator dependence, and heart failure. On 1/7/26 at 11:30 AM, V15 Shift Coordinator / Certified Nursing Assistant (CNA) and V16 CNA entered R1's room to provide incontinence care. R1 had a moderate bowel movement that was tar-like. V16 started with R1 being on her back and cleaning the vaginal area. V15 then rolled R1 to her right side and V16 began cleaning R1's buttocks. V16 wiped R1's stool from the top of her buttocks toward her vagina; V16 wiped in this direction twice. V15 spoke quietly and inaudibly to V16 after she had wiped her stool in the direction of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-08-11 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide 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 residents with urinary catheter care. This applies to 6 of 6 residents (R1, R2, R3, R4, R5, and R6) reviewed for urinary catheters.The findings include:1. On 8/09/2025 at 10:45 AM, R1 was sitting in his wheelchair. R1's urinary catheter tube had amber urine with sediment. R1 said he had recurrent UTIs (urinary tract infections) and was receiving an oral antibiotic. R1 had an open urinary piston syringe with a bottle at bedside. R1 said the nurse would frequently irrigate his catheter because it would get clogged often. R1 said on 8/05/2025 by V11 (Licensed Practical Nurse/LPN) changed his catheter because there was no urine output. R1 said the nursing staff was emptying his catheter but not cleaning it frequently. R1 continued to say that he was dependent on the facility staff to care for his catheter. Then V4 (Certified Nurse Assistant/CNA) came to assess R1's urinary catheter. R1's catheter tube was underneath and over (in an upwards direction) in front of his incontinence brief, not secured. R1's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-05-23 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to label residents' opened insulin pens and vials with the residents' name, opened-on, and expiration dates, and failed to remove expired medication. This applies to 7 of 8 residents (R30, R31, R48, R54, R64, R67, R189) reviewed for medications in a sample of 33. The findings include: On [DATE] at 10:54 AM, on the 2nd floor, inside V10's (LPN-Licensed Practical Nurse) medication cart, the following observations were made: 1. R48's Toujeo insulin (Glargine Pen) had no open or expiration date. R48's POS (Physician Order Set) shows an order of Toujeo SoloStar Subcutaneous Solution Pen-Injector 300 Unit/ML (Milliliters) (Insulin Glargine)-Inject 22 units subcutaneously every 12 hours. 2. R189's Glargine insulin had no open or expiration date. R189's POS shows an order of Insulin Glargine Solostar Subcutaneous Solution Pen-Injector 100 Unit/ML (Insulin Glargine)-Inject 60 units subcutaneously two times a day. There was a Humalog Kwik pen with no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-23 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide nail care to residents who require assistance. This applies to 3 of 3 residents (R1, R81, and R86) reviewed for activities of daily living (ADL) care in a sample of 33. The findings include: 1. R81 is a [AGE] year-old male with severe cognitive impairment as per the MDS dated [DATE]. The MDS also documents that R81 is dependent on personal hygiene. On 05/20/25 at 01:44 PM, R81 was on his bed and had long nails with a brownish substance accumulated underneath nails, with a left contracted hand and right partially contracted hand. On 05/20/25 at 01:50 PM, V27 LPN (Licensed Practical Nurse) stated CNAs (Certified Nursing Assistants) or activity aides should trim residents' nails and that R81's long nails with contracted left hand can cause a palm ulcer. R81's ADL care plan documented performance deficit and impaired ability with dressing and grooming, such as unable to complete tasks with personal hygiene. The ADL care plan…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-23 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to assess and obtain treatment orders for a resident with a laceration. This applies to 1 out of 1 resident (R340) reviewed for wound treatments in a sample of 33. The findings include: On 5/20/2025 at 10:35 AM, R340 was noted with a wrapped gauze dressing on right lower leg. The gauze was brown in color with dried blood stains and was unraveling. R340 said on 5/18/2025, her right leg caught on her wheelchair and she sustained a laceration. R340 said the wound was bleeding too much that she was sent to a local hospital where she got eleven stitches. R340 said no staff has come to assess her wound and the dressing on her wound has not been changed since she returned from the hospital. On 5/21/2025 (three days after R340 returned from the hospital) at 8:57 AM, R340's right leg wound dressing still had the same dried blood stains and the gauze was still unraveling. On 5/21/2025 at 9:05 AM, V15 (LPN- Licensed Practical Nurse) reviewed R340's POS (Physician Order Sheet) and said she cannot find any treatment orders…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-23 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to follow treatment orders as prescribed for residents with pressure wounds. This applies to 2 of 4 residents (R128 and R8) reviewed for pressure injuries in a sample of 33. The findings include: 1. On 5/21/2025 at 9:00 AM, V6 Wound Care Nurse (WCN) said R8 had a present-on-admission stage 4 pressure injury to her sacrum. V7 (WC Aide) assisted V6 with changing R8's sacral wound dressing. V6 removed a white bordered gauze dressing with moderate amount of serous sanguineous drainage (no other dressing was present). V6 said R8's ordered treatment included collagen (tissue growth stimulator) and calcium alginate (absorbent) dressings. V6 said R8's wound had slough tissue and undermining approximately from 5 o'clock through 8 o'clock. V6 said she was unsure why R8's ordered treatment dressings were not followed. V34's (WC NP/Nurse Practictioner) Wound Assessment Report dated 5/16/2025 said R8's stage 4 sacrum wound status showed delayed wound closure. The report said the wound measured 4.5 cm x 2.0 cm x 0.5 cm with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-23 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure services were provided to residents with indwelling urinary catheters in a manner to prevent infection. This applies to 2 of 2 residents (R441 and R58) reviewed for urinary catheters. The findings include: 1. On 5/20/25 at 12:04 PM, R441 was noted with indwelling urinary catheter draining cloudy yellow urine. R441 said the staff in the facility empty the urine from his drainage bag, but they don't ever clean his urinary catheter tubing. R441 said only the doctor at the doctor's office cleaned the tubing. On 5/22/25 surveyor asked to observe catheter care and at 10:11 AM, V11 and V12 (Restorative Aides) were observed providing catheter care for R441. Prior to the start of catheter care, R441's catheter drainage bag was noted to be hanging on the lower side rail of R441's bed, with the bottom of the bag resting on the floor. Prior to starting urinary catheter care, V11 and V12 noted that R441 had a bowel movement. V11 provided incontinence care first. While R441 was lying on his left side, she cleaned…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 35 citations
- Potential for harm · Dcited before2025-05-23 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to process reccommendations for and then provide residents their dietary nutritional supplements. This applies to 3 of 3 residents (R57, R4, and R8) reviewed for nutrition in a sample of 33. The findings include: 1. On 5/21/2025 at 12:10 PM, V11 (Restorative Aide) was feeding R57 in the dining room. R57 appeared thin. At 12:40 PM, V11 said she finished feeding R57, and R57 had consumed approximately less than 20% of her lunch. On 5/22/2025 at 12:20 PM, R57 was in bed for lunch. V24 (Agency Certified Nurse Assistant/CNA) said she tried to feed R57 her lunch, but she refused. V24 said she would ask the nurse for R57's prescribed supplement drink. On 5/22/2025 at 11:30 AM, V23 (Registered Nurse/RN) reviewed R57's orders. V23 said R57 had an order to receive 237 ml (milliliters) of her nutritional supplement twice a day. On 5/22/2025 at 1:00 PM, V26 (Registered Dietician/RD) said R57 was being monitored weekly for her significant weight loss. V26…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-23 · tag F0745 — failed to provide medically-related social services — isolatedProvide medically-related social services to help each resident achieve the highest possible quality of life.
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 the interview and record review, the facility failed to coordinate transportation procedure/activities to avoid several missed appointments to residents. This applies to 3 of 3 residents (R52, R91, R127) reviewed for outside appointments and transportation in a sample of 33. The findings include: 1. R91 is a [AGE] year-old female with cognition intact as per the Minimum Data Set (MDS) dated [DATE]. On 5/21/25 at 11:15 AM, during resident groups, R91 stated she went for an ortho appointment yesterday and couldn't see the Ortho physician as the facility didn't send the proper paperwork. R91 stated she needed to go back again. R91 stated the nurse didn't know about R91's appointment to prepare the paperwork for it. R91 blamed V18 (Transportation Coordinator) for not communicating with nurses. R91 stated it was not the first time she missed my appointments. R91's nursing progress note dated 5/21/25 documents that R91 had an ortho appointment yesterday and was unable to be seen so it needed to be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-23 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
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 administer medications as ordered. There were 25 opportunities with 3 errors resulting in a 12% error rate. This applies to 2 of 7 residents (R127, R190) observed during the medication pass. The findings include: 1. On 5/21/25 at 8:05 AM, V16 (RN-Registered Nurse/Agency) administered one pill of Zinc 50 MG (Milligrams) to R127. Review of R127's POS (Physician Order Sheet) shows an order of Zinc Sulfate Oral Tablet 110 MG (Milligrams)-Give 1 tablet my mouth two times a day. On 5/21/25 at 2:00 PM, surveyor went upstairs and checked V16's medication cart with her. V16 showed surveyor the house stock bottle where she pulled the Zinc from. On the bottle, it showed Zinc 50 MG. V16 stated she did not give the correct dosage. V16 said, I'm aware of the problem. That's not enough as per the doctor's orders. The doctor should have been notified to change the order. Sometimes, before the end of my shift, I will go give her another 50 MG of the Zinc tablet, but I don't document that. I know, it doesn't solve the problem…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-23 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to cohort and implement transmission-based precautions for a resident with an acute GI (gastrointestinal) infection. The facility also failed to follow Enhanced-Barrier Precautions (EBP). This applies to 3 out of 5 residents (R48, R74, R45) reviewed for infection control in a sample of 33. The findings include: 1. On 5/21/2025 at 2:45 PM, V5 (Infection Preventionist/IP Nurse) said R48 started having acute diarrhea on 5/12/2025. V5 said R48's stool was collected on 5/12/2025 to screen for C. difficile (an acute contagious GI infection). V5 said R48's stool resulted positive for C. diff on 5/14/2025 and was started on Vancomycin (antibiotic) treatment. V5 confirmed the facility had other available rooms to move R74 (R48's roommate). V5 said R74 and R48 were roommates until 5/15/2025 (three days later). V5 said R48 should have been placed in contact transmission based precautions when he was suspected to have C. diff infection. V5 said R74 was at risk for infections and should have been moved immediately when R48…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-23 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to implement it's antibiotic stewardship program to monitor usage of prescribed antibiotics for residents. This applies to 2 out of 3 residents (R109 and R85) reviewed for antibiotic use in a sample of 33. The findings include: 1. On 5/21/2025 at 2:15 PM, V5 (Infection Preventionist/IP Nurse) said as part of the facility's antibiotic stewardship program she reviews residents who are prescribed antibiotics, including their laboratory results, to ensure they are receiving appropriate antibiotic treatment. V5 said nurses were responsible for initiating a McGeer's assessment form when receiving orders for antibiotics. V5 continued to say she then reviews and completes the assessment forms to determine if the residents met the criteria for the use of their prescribed antibiotics. V5 said R109 was started on an antibiotic for a UTI (urinary tract infection) on 5/17/2025. V5 said R109 had an abnormal urinalysis (UA) specimen that resulted on 5/18/2025. V5 said she noted today, on 5/21/2025 (four days later) that R109's UA specimen…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-17 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to assess and treat a wound when it was first identified. This applies to 1 (R1) of 3 residents reviewed for wound care in the sample of 3. The findings include: R1's admission Record (Face Sheet) showed an admission date of 11/22/24. The Face Sheet showed diagnoses to include but not limited to Alzheimer's, Pressure ulcer, contractures of the legs, failure to thrive, and palliative care. R1's admission Minimum Data Set (MDS) from 11/26/24 showed he had short and long-term memory loss. The MDS showed he had limited range of motion in all extremities. The MDS showed R1 was dependent upon staff for every activity of daily living to include oral care, feeding, toileting hygiene, dressing, and personal hygiene. On 1/13/25 at 11:36 AM, V11 (R1's family) addressed an email to the state health department. The email showed, V11 was at the facility on 1/7/25, she was in R1's room during incontinence care, and she noted a wound to R1's scrotum that she was not previously aware of. On 1/16/25 at 10:00 AM, V4 (Wound Care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-17 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to handle soiled cleaning supplies and soiled bedding in a manner to prevent cross-contamination. This applies to 1 (R1) of 3 residents reviewed for incontinence care in the sample of 3. The findings include: On 1/16/25 at 9:20 AM, R1's room had an odor of feces. V5 (CNA-Certified Nursing Assistant) was providing incontinence care for R1. V5 stated R1 had a bowel movement, and she was cleaning him up. V5 had placed R1's soiled bedding on the floor and she had placed a stool covered washcloth on the bedside nightstand. R1 also had a name band on to his left wrist. The name band had a brown smear that appeared to be stool. V5 did not remove the name band. On 1/16/25 at 1:04 PM, V9 (Licensed Practical Nurse-LPN) stated the substance on the name band appeared to be feces. V9 stated the purpose of the name band is for identifying residents on the memory care unit. On 1/16/25 at 12:45 PM, V11 (R1's Family) stated she had visited R1 on 1/15/25. V11 stated R1's hands were covered in stool, and it also was on his name…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-20 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to protect a resident's right to be free from physical abuse. This failure affected 2 of 5 residents (R1 and R2) reviewed for physical abuse and resulted in R3 hitting R1 and R2 on the head. The findings include: The facility's Abuse Investigation Report submitted to Illinois Department of Public Health on 11/18/24 states, On 11/18/24 at approximately 18:15 (6:15pm) [R3] allegedly engaged in physical altercation with residents [R1] and [R2] after [R3] got a hold of a decorative flagstick and started hitting both residents with a stick. All residents have been separated immediately. No injury was noted to [R1] at this time. Noted bleeding on [R2's] head at this time . [R1] and [R2] will be sent out to ER for further evaluation . Police . notified . On 12/19/24 at 10:14 AM, R3 was sitting in a chair by nurse's station. R3 said, he may have gotten into a situation with another resident, and he may have possibly hit another resident, or another resident may have possibly hit him. R3's Face Sheet shows the following diagnoses of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-09 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident was provided hand splints to prevent a resident's further decrease in range of motion as recommended by the Therapy Department. This applies to 1 of 3 residents (R4) reviewed for physical therapy in the sample of 6. The findings include: On April 30, 2024, at 9:25 AM, R4 was lying in bed in her room. R4 had a tracheostomy in place connected to a ventilator. R4 had a gastrostomy tube in place connected to tube feeding. R4's eyes were open. R4 did not respond to being spoken to or following commands such as raising her hands, blinking on command, or following movements across the room. R4 was not wearing hand splints. Intermittent observations were made of R4 on April 30, 2024, from 9:25 AM to 3:30 PM. R4 was not observed wearing hand splints during the observation period. On April 30, 2024, at approximately 3:15 PM, V18 (Restorative Nurse/LPN-Licensed Practical Nurse) said there was no restorative aide working all day,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-09 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident received scheduled pain medication as ordered. This applies to 1 of 3 residents (R4) reviewed for improper nursing care in the area of pain in the sample of 6. The findings include: On April 30, 2024, at 9:25 AM, R4 was lying in bed in her room. R4 had a tracheostomy in place connected to a ventilator. R4 had a gastrostomy tube in place connected to tube feeding. R4's eyes were open. R4 did not respond to being spoken to or following commands such as raising her hands, blinking on command, or following movements across the room. The EMR (Electronic Medical Record) shows R4 was admitted to the facility on [DATE]. R4 has multiple diagnoses including, traumatic subdural hemorrhage with loss of consciousness of unspecified duration, elevated white blood cell count, contracture of right upper arm muscle, tracheostomy, cervical disc degeneration, respiratory failure, anemia, encephalopathy, dependence on respirator, alcohol abuse,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-05 · tag F0554 — patternAllow residents to self-administer drugs if determined clinically appropriate.
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 obtain physician orders for resident medications to be at the bedside. The facility also failed to complete self-administration of medication assessments for residents. This applies to 4 of 4 residents (R62, R109, R21, R88) reviewed for medications in a sample of 30. The findings include: 1. On 4/2/24 at 10:23 AM, on R62's end table, the following medications were observed to be on top of his end table: Albuterol Sulfate Inhalation Aerosol HFA 90 MCG (Micrograms), Pulmicort flex inhaler 180 MCG, Tiotropium Bromide Inhalation Powder 18 MCG per capsule, and Mometasone Furoate nasal spray. R62 stated, They are always kept here. Nurses never take them back. I already know how to take them. A nurse never taught me. There's no need for that. R62's face sheet shows diagnoses of chronic obstructive pulmonary disease and asthma. R62's MDS (Minimum Data Set) dated 1/5/24 shows a BIMS (Brief Interview for Mental Status) score of 15, which means he…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-05 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
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 intravenous medications were administered by qualified staff. This applies to 5 of 5 residents (R24, R95, R476, R477, and R478) reviewed for intravenous therapy in a sample of 30. The findings include: 1. On 4/03/2024 at 9:09 AM, V24 (Agency Licensed Practical Nurse/LPN) reconstituted and administered R477's Micafungin IV (intravenous) medication through her right upper arm midline (long peripheral catheter) with the use of a dial flow drip regulator. R477's Order Review Report dated 4/03/2024 showed an order for Micafungin Sodium Intravenous Solution Reconstituted 100 MG Use 100 ml intravenously one time a day for Infection for 20 days and RUE Midline single lumen (non-valved)-Flush lumen with 10 ML 0.9% NS before & after antibiotic infusion. R477's MAR (Medication Administration Record) for April 2024 showed V24 (Agency LPN) administered three doses of the Micafungin IV medication. 2. On 4/03/2024 at 3:26 PM, V24 (Agency LPN) stated she routinely works on the same unit and frequently administers…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-04-05 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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 incontinence care and respond to call lights in a timely manner. This applies to 8 of 8 residents (R11, R19, R40, R50, R56, R92, R99 and R105) reviewed for incontinence care in a sample of 30 residents. Findings include: 1. R99 currently residing on the memory care unit. The EMR (Electronic Medical Record) shows R99 was admitted to the facility on [DATE]. R99 has diagnoses that includes dementia, anxiety, and chronic kidney disease. R99's physician orders include 1500 ml (Milliliter) fluid restriction in 24 hours. R99's care plan dated 3/11/24 states he has extensive care needs and requires the support services of the long-term care setting. R99 has the potential for impaired skin integrity related to fragile skin, impaired mobility, occasional incontinence of bowel and bladder, medical diagnosis of dementia chronic kidney disease, essential tremors, and use of diuretics. Interventions include to keep skin clean and dry. R99 is at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-04-05 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. R99 currently residing on the memory care unit. The EMR (Electronic Medical Record) shows R99 was admitted to the facility on [DATE]. R99 has diagnoses that includes dementia, anxiety, and chronic kidney disease. R99's care plan dated 3/11/24 states he has extensive care needs and requires the support services of the long-term care setting. On 4/02/24 at 10:08 AM, during the room observation V32 (CNA--Certified Nursing Assistant) was observed providing incontinence care to R99. V32 threw the two-urine saturated disposable briefs on the floor. V32 with same soiled gloves went to the wardrobe and put one pair of clean briefs on R11's (R99's roommate) bed. V32 then picked the soiled briefs off the floor placed them in a plastic bag then threw the bag of soiled briefs on the floor. V32 then applied a clean brief to R99. V32 removed her soiled gloves and put on a new pair of gloves without performing hand hygiene. V32 went in bathroom to get wet towel to clean R99's roommate R11. 3. R11 currently residing on the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-04-05 · tag F0881 — failed to use antibiotics responsibly — patternImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to utilize a standardized tool to determine the necessity of antibiotics prescribed to residents. This applies to 4 of 4 residents (R32, R41, R121, R176) reviewed for antibiotics in a sample of 30. The findings include: On 4/3/24 at 11:30 AM, surveyor reviewed the infection control binder in the presence of V5 (Infection Preventionist/Registered Nurse/Assistant Director of Nursing). There were no McGeer's criteria forms for residents who were prescribed antibiotics within the last 3 months. V5 stated that he is covering for the previous infection preventionist because she is on vacation. V5 stated he will look in the computer to see if it was done. 1. R32's POS (Physician Order Sheet) shows an order for Levaquin Tablet 250 MG (Milligrams) (Levofloxacin)-Give 1 tablet by mouth one time a day for infection for 5 days (Start date of 3/31/24 with an end date of 4/5/24). There was no McGeer's criteria uploaded into her medical record. 2. R41's POS shows an order for Levofloxacin Intravenous Solution (Levofloxacin)-Use 750 MG…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-05 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure call lights were within residents' reach. This applies to 3 out of 3 residents (R2, R33 and R66) reviewed for call lights in the sample of 30. The findings include: 1. On 4/2/2024 at 10:21 AM, R2 was in bed and coloring a book. Call light was noted on the floor on the right side of her bed. R2 stated she uses the call light to call for help because she needs help with incontinent care and wants it to be accessible every time. R2 stated staff often forgets to put the call light where she can reach it. R2's MDS (Minimum Data Sheet) dated 1/17/2024 documents R2 has moderately impaired cognitive skills, has no impairment with upper extremities and is frequently incontinent of bowel. R2's Care plan dated 4/22/2024 documents R2 requires assistance with ADLs (Activities of Daily Living) with intervention to keep call light within reach. 2. On 4/2/2024 at 9:57 AM, R33 was in bed. Call light was not within reach and noted on her dresser on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-05 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to have the required documentation in the medical record of residents who had pacemakers. This applies to 2 of 4 residents (R86, R91) reviewed for pacemakers in a sample of 30. The findings include: 1. On 04/02/24 11:45 AM, R91 was lying in bed. R91 was nonverbal, had a tracheostomy and was on a ventilator. R91's face sheet shows diagnoses of essential hypertension, paroxysmal atrial fibrillation, heart failure and presence of cardiac pacemaker. R91's POS (Physician Order Sheet) does not show an order for pacemaker. It does not show parameters on how often to check the pacemaker. R91's MDS (Minimum Data Set) dated 3/11/24 under Section C-Cognitive Patterns shows a blank score under BIMS (Brief Interview for Mental Status) and he scored a 3 under cognitive skills for daily decision making, which means he is severely impaired. R91's admission assessment dated [DATE] shows that the nurse checked under the cardiac section that R90 did not have a pacemaker,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-05 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids 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 observation, interview, and record review the facility failed to change a resident's midline catheter dressing, measure, and document the external length of the catheter and arm circumference per facility policy. This applies to 1 of 5 residents (R476) reviewed for midline catheters in a sample of 30. The findings include: The EMR (Electronic Medical Record) showed R476 was admitted to the facility on [DATE] with multiple diagnoses including intra-abdominal infection. R476's MDS (Minimum Data Set) dated 3/31/2024 showed he was receiving IV (intravenous) antibiotic treatment. On 4/02/2024 at 10:36 AM, R476 had an intravascular midline catheter to his right upper arm. R476's midline catheter had a transparent dressing dated 3/24/2024. On 4/04/2024 at 11:24 AM, R476 had the same transparent dressing dated 3/24/2024. R476's Order Review Report dated 4/03/2024, showed an order for RUE-right upper extremity Midline single lumen (non-valved)-cleanse with chlorhexidine and cover site with transparent dressing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-05 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to immediately address a resident screaming in pain. This applies to 1 of 1 resident (R75) in a sample of 30 residents. Findings include: R75 currently residing on the memory care unit. The EMR (Electronic Medical Record) shows R75 was admitted to the facility on [DATE]. R75 has diagnoses that include congestive heart failure, anxiety, severe intellectual disabilities, schizoaffective disorder, and type 2 diabetes. R75's physician orders include heel protectors, low air loss mattress and pain assessment every shift. Acetaminophen 650mg every six hours as needed for pain. The care plan dated 2/27/24, R75 is at risk for impairment to skin integrity and is at risk for further skin impairment related to fragile skin, impaired ADL (Activity of Daily Living) / mobility, incontinence, and history of pressure injury. R75 is at risk for pain related to chronic physical disability. Interventions include administer pain medication per Medical Doctors…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-05 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to dispose of controlled medications per facility policy. This applies to 3 of 3 residents (R4, R58, and R108) reviewed for controlled medications in a sample of 30. The findings include: 1. On 4/03/2024 at 2:53 PM, R58's lorazepam 0.5mg (milligrams) medication punch card was observed with the #3 pill slot punched open, with tape over it with a pill inside. R58's Order Review Report dated 4/03/2024 did not show any order for lorazepam. 2. On 4/03/2024 at 2:53 PM, R108's hydrocodone-APAP 5-325mg medication punch card was observed with the #9 pill slot punched open, with a band-aid over it with a pill inside. V25 (Registered Nurse/RN) was present during R58 and R108's observations and stated the medications should have been wasted appropriately and not placed back into the punch cards. R108's Order Review Report dated 4/03/2024 showed an order for Norco Oral Tablet 5-325 MG Give 1 tablet via G-Tube two times a day for pain. 3. On 4/03/2024 at 3:12 PM, R4's tramadol 50mg medication punch card was observed with the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-03-12 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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 toileting hygiene for residents who required assistance with incontinence care. This applies to 4 of 4 residents (R1, R4, R5, R6) reviewed for ADL's (Activities of Daily Living) in the sample of 6. The findings include: 1. On March 8, 2024, at 11:14 AM, V3 (CNA/Certified Nurse Assistant) assisted R1 to the resident bathroom. V3 lowered R1's pants and opened R1's incontinence brief. R1's incontinence brief had a second incontinence brief inside. At 1:45 PM, V3 stated some of the residents were heavy wetter's but the residents should only be wearing one incontinence brief. The EMR (Electronic Medical Record) shows diagnoses including paralytic syndrome, epilepsy, chronic kidney disease, type 2 diabetes mellitus, schizoaffective disorder, hypertension, gout, mild cognitive impairment, pain in unspecified joint, hearing loss, bipolar disorder, gastro-esophageal reflux disease, hydronephrosis, and obstructive and reflux uropathy. R1's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-19 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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 notify the family/emergency contact of resident's change in condition. This applies to 1 of 3 residents (R1) reviewed for change of condition notification in a sample of 4. Findings include: On 10/17/23 at 11:00 AM, R1 said she does not remember what happened to her on 9/22/23. R1 said the last thing she remembers is eating breakfast that morning and then waking up in the hospital emergency room. R1 said she has family listed as an emergency contact that she wants notified when necessary and her emergency contact was not notified on 9/22/23. On 10/18/23 at 3:51 PM, V12 (R1's emergency contact) said she was never notified by the facility on 9/22/23 that R1 was transferred to the hospital or had any change of condition. V12 said she wants to be notified about any changes with R1. On 10/18/23 at 2:43 PM, V10 (LPN/Licensed Practical Nurse) said the reason R1 was sent out to the hospital on 9/22/23 was because her oxygen dropped below, and she was sleepy and had altered mental status which was not her baseline. V10 said she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-19 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 free from mental abuse. This applies to 2 of 4 residents (R1 and R4) reviewed for abuse in a sample of 4. The findings include: 1. R1's Face Sheet shows the following medical diagnoses: Peripheral Neuropathy, Cellulitis of Left Lower Limb, Edema, Carcinoma of Left Breast, Panic Disorder, Anxiety, and Morbid Obesity. R1's MDS (Minimum Data Set) dated 10/6/23 shows her cognition is intact and she requires moderate assistance with dressing her lower body and putting on and taking off socks and footwear. On 10/17/23 at 11:00 AM, R1 said V10 (LPN/Licensed Practical Nurse) acts apathetic towards her and when V10 is her nurse, R1 feels anxious wondering what kind of mood V10 is going to be in that day. R1 said one day when V10 was applying steroid cream to R1's legs, V10 said to R1 can't you do this yourself? On another occasion R1 asked V10 to put her socks on and V10 said, can't you do it yourself? and R1 told V10 that she was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-03-01 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents were treated with dignity during care. This applies to 4 of 27 residents (R54, R120, R100, R24) reviewed for dignity in the sample of 27. The findings include: 1. On 2/27/23 at 11:30 AM R54 stated, About 2 weeks ago the CNA named (V22) came in to prepare me for a bed bath. V22 then stated, I'll be right back and left me on the bed completely naked and didn't come back. I found out she was on break. The nurse came in and said, she has a right to take a break. Then when she came back and she knew that I complained she said to me You need me, I don't need you. R54's Minimum Data Set assessment dated [DATE] shows that R54 has mild cognitive impairment and requires extensive assist of 1 staff for personal hygiene. On 2/28/23 at 1:10 PM V22 was asked if she recalled giving R54 a bed bath about 2 weeks ago. Without prompting V22 stated, Did she say I left her naked? I wouldn't do nothing like that, that wasn't me. I don't do that.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-01 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
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 the abuse policy for 1 of 27 residents (R28) reviewed for abuse in the sample of 27. The findings include: On 2/27/23 at 11:24 AM, R28 stated, last week on Friday morning around midnight or 1:00 AM, my roommate R108 took this wooden back scratch/reacher that I had on my bedside table and hit me three times in my right hip. Staff scooted my bed all the way over to the window but left her R108 in the room, and staff did not stay in the room with us overnight. I did not sleep that night because R108 kept saying under her breath I am going to get you. On 02/28/23 at 10:37 AM, V14 (Social Services) stated, I found out when I came into work on Friday at around 8:30-8:45 AM about the incident between R28 and R108. We then put R108 on a 1:1 and had her petitioned and sent out to the hospital. On 3/1/2023 at 7:22 AM, V13 (Certified Nursing Assistant/ CNA) stated, I was here the night that R28 was hit by R108. We tried to move R108 out of the room but there were no empty beds, so we scooted R28's bed all the way over to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-01 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure abuse was reported to the administrator immediately for 1 of 27 residents (R28) reviewed for abuse in the sample of 27. The findings include: On 2/27/23 at 11:24 AM, R28 stated, last week on Friday morning around midnight or 1:00 AM, my roommate R108 took this wooden back scratch/reacher that I had on my bedside table and hit me three times in my right hip. On 02/28/23 at 10:37 AM, V14 (Social Services) stated, I found out when I came into work on Friday at around 8:30-8:45 AM about the incident between R28 and R108. We notified V1 (Administrator) immediately of the incident that morning when we found out. On 3/01/23 at 10:04 AM, V1 stated, I was not notified the morning of 2/24/23 of the incident between R28 and R108 that happened between 12-1:00 AM. Any abuse is supposed to be reported to me immediately. Staff call me all hours of the night and day and I should have been called by V15 (agency nurse) immediately. A facility Abuse Report Initial Form completed by V1 (Administrator) on 2/24/23 shows he was notified on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-01 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure a resident was protected following resident to resident abuse for 1 of 27 residents (R28) reviewed for abuse in the sample of 27. The findings include: On 2/27/23 at 11:24 AM, R28 stated, last week on Friday morning around midnight or 1:00 AM, my roommate R108 took this wooden back scratch/reacher that I had on my bedside table and hit me three times in my right hip. Staff came to the room and scooted my bed all the way over to the window but left her R108 in the room, the staff did not stay in the room with us overnight. I did not sleep that night because R108 kept saying under her breath I am going to get you. On 3/1/2023 at 7:22 AM, V13 (Certified Nursing Assistant/ CNA) stated, I was here the night that R28 was hit by R108. Around 12-1:00 AM on Friday morning I responded to their room because the call light was on. I walked in to see R108 holding a wood back scratch stick, R28 told me that she had been hit in the side by R108. We tried to move R108 out of the room but there were no empty beds, so we scooted R28's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-01 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
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 R18 with a communication board for one of twenty-seven residents reviewed for Activities of Daily Living in the sample of twenty-seven. The Findings include: R18's current Care Plan on 03/01/2023 shows, multiple diagnosis including Aphasia- (inability to formulate language) following cerebral infarction. On 02/28/2023 at 9:53AM, R18 was sitting in a wheelchair in her room. V19 LPN-Licensed Practical Nurse attempted to provide R18 with her morning medication. R18 refused to take her medication. R18 was speaking with garbled speech, gesturing with her left arm and projected a facial expression that she was upset. V19 LPN attempted to clarify the issue with R18 but was unable to understand R18. On 03/01/2023 at 9:10AM, R18 was observed laying in bed. R18 smiled and spoke calmly in garbled speech and with gestures. When asked if she had access to a communication board R18 looked around the room and shrugged using her left arm and gave a facial express that said, I do not know. On 03/01/2023 at 9:15AM, V19…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-01 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents who are totally dependent and residents who require extensive assist with Activities of Daily Living (ADLs) received assistance with incontinence care and showers. This applies to 3 of 27 residents (R13, R24, R59) reviewed for ADLS in the sample of 27. The findings include: 1. R13's face sheets shows she is a [AGE] year old female with diagnosis including hemiplegia and hemiparesis following cerebral infarct affecting right dominant side, dysphagia, mild-protein calorie nutrition, and stage 4 sacral pressure ulcer. R13's Minimum Data Set assessment dated [DATE] shows her cognition is moderately impaired and total dependent with two staff assist with bed mobility, transfers, toileting, limited range of motion with impairments to one side of his upper and lower extremity and frequently incontinent of urine and stool. On 2/27/23 at 10:05 AM, R13 was lying in bed. V10 and V11 (Both Certified Nursing Assistant's-CNA) provided…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-01 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure a treatment dressing was in place for a resident with a skin alteration. This applies to 1 of 1 resident's (R4) reviewed for quality of care in the sample of 27. The findings include: 1. R4's Physician Order Sheets (P.O.S.) dated through February 2023 shows he has diagnosis including dementia, personal history of traumatic brain injury, blindness, aphasia following cerebrovascular disease, hemiplegia affecting right dominant side and muscle wasting. R4's nurses note dated 2/24/23 documents R3 has a skin alteration to the right lateral leg. R4's Skin Alteration report dated 2/23/23 documents right thigh skin tear measuring 4 cm x 2 cm. On 2/27/23 at 10:57 AM, R4 was observed in his room sitting in his wheelchair a large open area to his right thigh without a dressing on. On 2/28/23 at 1:19 PM, V8 (LPN-Licensed Practical Nurse) stated one day last week staff noticed an abrasion on R4's right lateral thigh and not sure how the abrasion occurred she thinks maybe from the wheelchair. R4 is alert to self 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.
- Potential for harm · Dcited before2023-03-01 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure dressing changes were completed and dressings were re- applied for 2 residents with pressure injuries (R13, R24) and failed to ensure a resident was turned and repositioned (R24). This applies to 2 of 6 residents reviewed for pressure injuries in the sample of 27. The findings include: 1.) On 2/27/23 at 10:46 AM, R24 stated, I recently returned to the facility after being at a VA hospital for 2 months for wound care. I am a quadriplegic and cannot move my arms or legs. I have sores on my bottom, and no one has changed the dressings in a couple days. Staff are also not turning me and re-positioning me like they should. On 2/27/23 at 10:50 AM, V16 (R24's spouse) called his call phone and spoke with this surveyor. V16 stated, I am worried about his wound care we had him at a VA hospital to get his wounds on his bottom and calves healed. I was there yesterday for 4 hours, and no staff came into his room to turn or re-position him. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-01 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a splint was in place for a resident with impaired mobility. This applies to 1 of 7 (R13) residents reviewed for mobility in the sample of 27. The findings include: R13's face sheets shows she is an [AGE] year-old female with diagnosis including hemiplegia and hemiparesis following cerebral infarct affecting right dominant side, dysphagia, mild-protein calorie nutrition, and stage 4 sacral pressure ulcer. R13's Minimum Data Set assessment dated [DATE] shows her cognition is moderately impaired and total dependent with two-person assist with bed mobility, transfers, toileting and has limited range of motion with impairments to one side of his upper and lower extremity. R13's Physician Order Sheets dated through February 2023 shows orders to apply splint to right hand for 8 hours during the day. On 2/27/23 at 10:11 AM, R13 was observed laying in bed. Her right hand was clenched and without a splint in place. At 1:45 PM, R13's right…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-01 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure nutritional supplements were provided to a resident at risk for weight loss and failed to ensure a significant weight loss was reported. This applies to 2 of 12 (R70, R130) residents reviewed for nutrition in the sample of 27. The findings include: 1. R70's Physician Order Sheets dated through February 2023 shows she is a [AGE] year-old female with diagnosis including dysphagia, dementia, major depressive disorder, type 2 diabetes, and macular degeneration. The P.O.S. shows orders for a puree diet with nectar thick consistency and super mashed potatoes with gravy at lunch and dinner, magic cup (or equivalent) two times a day with meal and yogurt with meals. R70's Minimum Data Set assessment dated [DATE] shows her cognition is severely impaired and requires extensive one person assist while eating. R70's Dietary Evaluation dated 2/13/23 shows her weight at 124 lb. (pounds) at 68 inches (5 ft 8 inches) and her BMI (Body Mass Index) 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.
- Potential for harm · Dcited before2023-03-01 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and record review the facility failed to prevent a resident from receiving another resident's medication for 1 of 7 residents (R73) reviewed for pharmacy services in the sample of 27. On 2/27/2023 at 10:28 AM, V24 R73's Mom was interviewed at R73's bedside. V24 stated R73 had been given an iron (ferrous sulfate) tablet that wasn't ordered in the last two weeks. V24 said R73 was given another resident's medication in error. On 3/1/2023 at 9:30AM, V1 Administrator said R73 did receive an iron (ferrous sulfate) tablet in error. V1 said R73 was given an iron tablet in error. V1 said the iron tab was R73's roommate who was hospitalized at the time. The facility's Medication Variance Report dated 2/16/23 shows R73 was given 325mg of ferrous sulfate on 2/16/23, which was not R73's medication, and R73 did not have an active order for any ferrous sulfate dose. On 3/1/2023 at 11:38AM, V2 Director of Nursing (DON) stated every before every medication administration the nurse should check the 5 rights of medication administration, right patient, right medication, right dose,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-01 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
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 administer medications as ordered through the prescribed route. There were twenty-nine opportunities with three errors resulting in a 10.34% error rate. This applies to one of six residents (R100) observed in the medication pass. The findings include: On 03/01/2023 at 9:29 AM, R100 was observed laying in bed. V20 RN-Registered Nurse provided R100 liquid levetiracetam 1000 milligrams by mouth. When R100 drank the liquid she scowled and said, [NAME]! R100 was also provided amiodarone 200 milligrams by mouth and benztropine 0.5 milligrams by mouth. On 03/01/2023 at 9:29AM, V20 RN stated, R100 was receiving her medication through the gastric tube. She is now taking her medication by mouth. R100's Medication Administration Record on 03/01/2023 at 9:00 AM, shows, amiodarone hydrocholoride tablet 200 milligrams give one table via gastric tube one time a day for anti-arrythmia. Levetiracetam solution 100 milligrams per milliliter give ten…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$143,281 in federal fines across 2 penalties. 1 Medicare payment denial on record.
- $82,250 — penalty dated 2026-06-11
- $61,031 — penalty dated 2024-04-05
- Medicare payment denial — starting 2024-05-04 for 6 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.
Part of a chain
This home belongs to LEGACY HEALTHCARE — 89 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.9 | -1.9 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 1 of 5 | 2.5 | -1.5 vs chain |
| Quality measures | 3 of 5 | 3.3 | -0.3 vs chain |
The other 88 homes this chain runs (chain average 2.9★, per CMS)
Showing 40 of 88; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| DOROS GENERATION TRUST U/A/D 1/3/12 | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 50% | since 05/03/2017 |
| GPN FAMILY TRUST U/A/D 4/28/08 | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 50% | since 05/03/2017 |
| ELMBROOK HC REALTY, LLC | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | — | since 11/06/2015 |
| FORBRIGHT BANK | Organization | 5% OR GREATER SECURITY INTEREST; OPERATIONAL/MANAGERIAL CONTROL | — | since 07/31/2024 |
| SHABAT, MENACHEM | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/03/2017 |
| LEGACY HEALTHCARE FINANCIAL SERVICES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/06/2015 |
| LIYANAPATABENDI, CHOOL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/06/2015 |
| MORRIS, MARGAUX | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/11/2024 |
| MILLER COOPER & CO, LTD | Organization | ADP OF THE SNF | — | since 01/01/2024 |
CMS files one row per role, so the 18 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.
6 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.
About 84% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $3.2M paid to related parties — landlords or management companies under common ownership — equal to about 17% 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
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145339. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-23, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.