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Citadel Of Glenview,the

1700 East Lake Avenue, Glenview, IL 60025 · For profit - Limited Liability company · 135 certified beds · (847) 729-1300 Medicare & Medicaid certified

Call the home — (847) 729-1300 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0604) — cited Jul 2025Behavioral-health or dementia-care citations — no harm found (F0740, F0758)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (28% vs 45% nationally) — better care continuity
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)

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

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

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

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1412 Waukegan Rd · (847) 901-9880 · Call to confirm hours
Pharmacy
Walgreens<0.1 mi
1403 Waukegan Rd · (847) 998-1442 · Call to confirm hours
Grocery
1401 Waukegan Rd · (708) 533-2609 · Call to confirm hours
Park
1821 Maplewood Ln · (847) 724-5670 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 5 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 3 to 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased3.9%13.4%15.4%better
Long-stay residents who lose too much weight10.4%6.3%5.4%worse
Long-stay residents with a catheter left in their bladder1.0%0.9%0.9%worse
Long-stay residents with a urinary tract infection0.3%1.5%2.0%better
Long-stay residents with depressive symptoms93.2%54.2%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.8%3.1%3.3%worse
Long-stay residents whose ability to walk worsened7.6%14.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication17.5%18.3%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%91.8%95.3%typical
Long-stay residents with pressure ulcers7.4%4.8%4.7%worse
Long-stay residents with worsening bladder/bowel control21.9%20.6%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table30.5%21.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.5%2.2%1.4%typical
Short-stay residents given the seasonal flu vaccine100.0%63.1%79.4%better
Short-stay residents rehospitalized after admission22.1%26.1%22.6%typical
Short-stay residents with an outpatient ER visit8.1%13.9%12.0%better
Long-stay hospitalizations per 1,000 resident days2.172.021.67worse
Long-stay outpatient ER visits per 1,000 resident days1.522.221.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

55.6% 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 192 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

55.6%U.S. median 51.5%
Got home and stayed home
10.2%U.S. median 10.7%
Went back to hospital
66.7%U.S. median 56.6%
Met the expected recovery
0.32U.S. median 0.31
Therapy hours / resident / day
0.16hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 66.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 114 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.32 therapist hours per resident per day in 2026Q1 — more than 53% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 36% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF55.6%CMS range 48.0–61.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.2%CMS range 7.7–13.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge66.7%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge65.8%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge64.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.4%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.6%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.2%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.8%CMS range 4.9–11.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.301.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.70
RN hours/ resident / day
0.70
LPN hours/ resident / day
1.99
Aide hours/ resident / day
3.38
Total nurse hours/ resident / day
0.51
RN hoursweekends
28.0%
Total nursing turnover
30.0%
RN turnover

How full it usually is: this home is certified for 135 beds and averages 120.3 residents a day — about 89% occupied, or roughly 15 beds typically open. It runs fairly full. 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 3.38 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.70 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.99 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.96 hrs/resident/day on weekends vs 3.55 on weekdays — 17% thinner on weekends. RN hours go from 0.77 to 0.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 28% is below 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

9
deficiencies at the latest standard inspection (2025-07-25)
0
at the previous standard inspection (2024-08-29)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.

  • Potential for harm · E2025-07-25 · tag F0757 — failed to avoid unnecessary drugs — pattern
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to complete infectious screening assessment for resident started on antibiotics and formulate a care plan for its usage. The facility also failed to monitor behavior and medication side effects for resident on psychotropic medications. This deficiency affects all 4 residents (R3, R8, R123 and R129) in the sample of 25 reviewed for Unnecessary medications.Findings include: R3On 7/22/25 at 11:50AM, Observed R3 lying in bed watching TV. He is alert and oriented x 3. Reviewed R3's medical record. R3 was admitted on [DATE] with Chronic Obstructive Pulmonary, End Stage Renal disease, Dependence of renal dialysis, acquired absence of right and left below the knee amputation. Active physician order sheet indicated: Azithromycin oral tablet 500mg 1 tablet by mouth in the morning every MWF for prophylaxis PNA (Pneumonia) date 7/11/25. Infectious screening assessment for Antibiotic completed on 7/22/25 and Care plan for antibiotic usage as prophylaxis…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-25 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor 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 observation, interview and record review the facility failed to treat each resident with respect , dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality, and failed to provide a dignified dining experience for 1 of 3 residents observed during meal service in the resident's room for 1 of 3 resident's (R13) in a sample of 25. Findings include: On 7/23/2025 at 11:45am R13 was observed in bed with a meal tray in front of her the top lid off and a fork down in the food.On 7/23/2025 at 11:50am V20 (Certified Nursing Assistant-CNA) was observed escorting three residents to the dining area.On 7/23/2025 at 11:57am V20 said, I am (R13's) CNA, the nurse called me away to escort residents to the dining area, I'm in the process of assisting her with eating, she eats very well and needs full assistance. V20 was asked should her meal tray be uncovered while not eating. V20 said, Her food is not cold, the bottom tray is warm.On 7/23/2025 at 12:04pm V20 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-25 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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 prevention of using physical restraints to unnecessarily impede R9's freedom of movement affecting 1 of 1 resident (R9) reviewed for freedom of restraint in a total sample of 25. Findings Include:On 7/23/2025 at 12:45 PM, R9 was seated in the wheelchair with self-releasing belt applied around the chest-abdominal area. V18 (Korean Program Director) translated to R9 to demonstrate how to release the self-releasing belt. R9 was not able to remove the belt independently and was not able to follow command. V18 stated R9 is not able to release the belt on her own. On 7/23/2025 at 2:05 PM, V2 (Director of Nursing) stated self-releasing belt is removed by the resident without assistance from staff. V2 said R9 uses the self-releasing belt to prevent her from standing up. V2 said there was no restraint assessment completed for R9.Review of R9's medical records read: Initial admission Date: 11/18/2023. Diagnosis Information include Metabolic Encephalopathy, Unspecified Dementia, Unspecified Severity, 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-25 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to refer a resident to the appropriate state designated authority for a PASARR level 2 screening for evaluation and determination of newly evident serious mental illness related condition, for two of four residents (R12, R62) reviewed for a PASARR level 2 screening in a sample of 25. Findings include:1. On 7/23/25 at 12:23PM, V1(Administrator) said a level II PASARR was completed for R12 in 2018 and if a new mental diagnosis is added then a new level II PASARR should be completed by social services. On 7/23/25 at 12:52PM, V5 (Social Services) said in 2021 when the new diagnosis was added she was not working in the facility. V5 said she will find out if R12 needs a level II PASARR completed again. On 7/23/25 at 1:45PM, V5 said there is no level II PASARR for R12 completed after a new diagnosis and medication was added V5 said a level II PASARR should have been completed again to provide appropriate program and services to resident. An admission record indicates that R12 has a diagnosis of Major Depressive Disorder, recurrent,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-25 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure Preadmission Screening and Resident Review (PASARR, Level I and Level II) was conducted prior to admission affecting 2 of 2 residents (R91, R122) reviewed for PASARR in a total sample of 25.Findings Include:1. On 7/23/2025 at 12:35 PM, V19 (admission director) stated that the social service department should be the one to complete PASARR of every residents in the facility. On 7/23/2025 at 2:00 PM, V1 (Administrator) stated there was no PASARR completed for R122 prior to admission in the facility. V1 said that he is aware that PASARR needs to be done for all admissions to determine any specialized services to be provided. Review of records of R122 read; [AGE] year-old female patient initially admitted in the facility on 5/20/2022. R122 has diagnosis including Dementia, unspecified severity, with other behavioral disturbance, Unspecified psychosis not due to a substance or known physiological condition, Delusional disorder, bipolar…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-25 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide nail care to dependent resident. This deficiency affects one (R129) of three residents in the sample of 25 reviewed for ADLs (Activity of Daily Living) Program. Findings include: On 7/23/25 at 9:39AM, Observed R129 sitting in the dining room. He is alert and responsive in Spanish language. V8 WCN (Wound Care Nurse) said that he is confused. R129 needs assistance with ADLs and transfers. Observed long and dirty fingernails with black matter underneath the nails. V8 said the CNA (Certified Nurse Assistant) is responsible for providing nail care as part of the ADLs program.R129 was admitted on [DATE] with diagnosis listed in part but not limited to, Altered mental status, Dependence of renal dialysis, End stage renal disease (ESRD), Chronic Obstructive Pulmonary disease (COPD). MDS/Resident assessment dated [DATE] Section GG Functional abilities GG0130 Self-care indicated: Personal hygiene marked 2 Substantial/maximal assistance…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-25 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that no treatment medication is left at bedside without physician order. This deficiency affects one (R8) of three residents in the sample of 25 reviewed for Medication safety. Findings include: On 7/23/25 at 9:53AM, V8 WCN (Wound Care Nurse) and V21 Wound Tech assisted R8 to stand up from the wheelchair to perform skin check to sacral area. Observed R8's sacral area with redness. V21 Wound tech grabbed the nystatin powder bottle from the bedside table to apply. Surveyor asked if they are providing treatment to R8's sacral redness and leaving the medication at bedside. V8 WCN said the floor nurses are the one providing treatment to R8 for redness and no medication should be left at bedside. On 7/23/25 at 2:16PM, Informed V2 DON (Director of Nursing) of above observation and concern. V2 DON said that no medication should be left at bedside for safety unless order by physician. R8 was admitted on [DATE] with diagnosis listed in part…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-25 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to place EBP (Enhanced Barrier Precaution) signage and set up for resident on dialysis. The facility also failed to clean and disinfect vital signs equipment after resident use. This deficiency affects three ( R55, R7, R129) of three residents in the sample of 25 reviewed for Infection Control Management.Findings include: 1. On 7/22/25 at 10:24AM, V2 DON (Director of Nursing) presented list of residents on EBP. R129 was not listed in the list of residents on EBP. On 7/22/25 at 11:30Am, V14 LPN (Licensed Practical Nurse) said R129 is currently on dialysis. Observed R129's room with no signage for EBP and no EBP set up outside the door. V14 said R129 should be EBP due to his dialysis. V14 said she did not realize there is no signage posted and no EBP isolation cart set up outside the door. V14 said she will inform V3 ADON/Infection Coordinator to place a signage and set up for EBP for R129 On 7/22/25 at 2:16PM, V2 DON said residents 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-25 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    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 implement monitoring of antibiotics. This deficiency affects one (R14) of three residents in the sample of 25 reviewed for Antibiotic Stewardship Program. Findings include: On 7/24/25 at 11:25AM, V3 (Infection Preventionist) said residents should have an infection screening evaluation assessment completed upon the start of antibiotic medication. V3 said R14 should have an assessment completed on 7/14/25. V3 said when she is not in facility the assessments do not get completed on time since she is the only one to do them.On 7/24/25 at 1:55PM, V2 (Director of Nursing) said his expectations for antibiotic stewardship program are for residents to be screened at the start of antibiotics, the infection screening evaluation should be completed in the absence V3.R14 was admitted on [DATE] with diagnosis listed in part but not limited to local infection of the skin and subcutaneous tissue, unspecified. Physician order summary report: Doxycycline…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-04 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 assessed for self administering medications for 1 of 3 residents (R1) reviewed for medications. The findings include: R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include major depressive disorder, menopausal and perimenopausal disorder, anxiety disorder, insomnia, paranoid personality disorder, delusional disorders, and unspecified psychosis not due to a substance or known physiological condition. On 12/3/23 at 12:53 PM, R1 said, . I questioned how the Prevacid (acid reflux medication) kept changing. [The facility pharmacy] was handling the medications and I decided I didn't have to get them from them so insurance started sending them to me. I get them. I was taking them all appropriately and I got to have them in my room for awhile and then they came in and said I couldn't have them in the room anymore. They just came in today and took them. It was the administrator and the DON…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · D2023-12-04 · tag F0740 — failed to provide behavioral / mental-health care — isolated
    Ensure each resident must receive and the facility must provide necessary behavioral health care and 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 identify behaviors, failed to notify the psychiatric nurse practitioner of behaviors, and failed to provide appropriate behavioral health services to a resident with multiple mental health diagnoses for 1 of 3 residents (R1) reviewed for behavioral health services. This failure has resulted in R1 refusing to allow facility staff in her room, covering areas of the walls in her room with aluminum foil, towels, sheets, and covering the ceiling vent with plastic wrap. The findings include: R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include major depressive disorder, menopausal and perimenopausal disorder, anxiety disorder, insomnia, paranoid personality disorder, delusional disorders, and unspecified psychosis not due to a substance or known physiological condition. R1's facility assessment dated [DATE] showed no cognitive deficits and R1 to be independent in most cares. The same facility assessment…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-09-20 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record review, the facility failed to properly clean and sanitize service and dishware. This deficiency has the potential to affect 120 residents receiving food from the kitchen. Findings include: On 09/17/2023 at 9:34 am, during kitchen observation, V4 (Dish Washer) was observed putting dishes in the dishwasher. V3 (Dietary Aide) said V4 does not speak English surveyor asked V3 how the dishwasher temperatures are tested. V3 said a test strip is put in the dishwasher and a cycle is run, and after the washing cycle is complete, the temperature test strip should turn black to indicate the dishwasher washed/sanitized at the right temperature. V4 was asked to test the dishwasher temperatures. V4 put test strip on a plate and ran the dishwasher. Test strip came out white. V4 said the test strip should have turned black to indicate the dishwasher temperatures are on the right temperature. V4 tested the dishwasher 4 times and each time the test strips remained white. On 09/17/2023 at 10:20 am, V5 (Food Service Director) said he would test 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-09-20 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interview and record review, the facility failed to follow their policy on garbage disposal by failing to close lids of the dumpster. This deficiency has the potential to affect all 122 residents residing in the facility. Findings include: On 9/18/2023 at 11:36 am, V5 (Food Service Director) and surveyor went outside to observe the dumpster. The dumpster was observed open on both ends with garbage visible from the outside. V5 said the dumpster covers/lids should be pulled closed after garbage disposal, for infection control, to prevent rodents/rats from getting into the dumpster, and to prevent loose garbage from flying out of the dumpster, which can then spread disease and germs, and spreading germs. On 9/19/2023 at 10:59 am, V17 (Housekeeping/Laundry director) said garbage is collected from the soiled room designated for garbage by the housekeepers, then taken to the dumpster. V17 said the dumpster should be closed so that animals and rain do not get inside the dumpster, as an infection control prevention measure. V17 further stated It is a form of infection…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-09-20 · tag F0813 — pattern
    Have a policy regarding use and storage of foods brought to residents by family and other visitors.
    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 resident personal refrigerator temperatures were maintained at 41 degrees Fahrenheit, failed to clean personal refrigerators regularly to maintain a safe and sanitary environment for food storage, failed to date/label food items, and failed to Discard expired food items after 6 days for 4 residents (R72, R73 R112, R67) reviewed for personal refrigerators in a sample of 25. Findings included: On 9/17/23 at 10:35 AM, surveyor and V15 [Maintenance Director] made rounds and observed R72, R73, R112, and R67's personal refrigerators. The freezer sections were with thick layer of white ice covering the inside, outside and underneath the freezer sections. No thermometers inside the refrigerators, and personal food containers without dates or labels. The food containers were consisting of meat, salads, and cultural food items. On 9/17/23 at 11:05 AM, V15 stated, All the residents' personal refrigerators should have a thermometer inside, to make sure the refrigerator is at least 41 degrees Fahrenheit. I do not…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-20 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor 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 interview, and record review the facility failed to follow their resident rights policy by failing to allow one resident (R90's) durable power of attorney for health care, to enter the facility to visit R90. 1 resident (R90) out of 3 reviewed for resident rights in the sample of 25. Findings Include, R90's clinical record documents in part; R90 is a [AGE] year-old with medical diagnosis of dementia, osteoarthritis, essential hypertension, chronic kidney disease, dysphagia, anxiety and adult failure to thrive. Minimum data set [MDS] Brief Interview Mental Status score [5] dated (10/11/22) indicates R90 is severely cognitively impaired. On 9/19/23 at 3:30 PM, V34 [R90's Durable Power of Attorney of Health Care] per phone interview stated, I drive from down state Illinois and stay in a hotel for a week. During that time, I stay with R90 from 8am to 8PM. I feed, bathe, clothe, wash hair, and apply lotion to R90. I encourage her to drink fluids and provide social interaction due to R90 only speaks Korean 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-20 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to ensure proper grooming for one resident (R322) in a sample of 25 residents reviewed for activities of daily living care. Findings include: On 9/17/23 at 11:50 AM, Observed R322 sitting in a wheelchair in R322s room. Observed R322 fingernails to be long and dirty. R322 stated I want my fingernails cut. My husband (V31) asked last week. He went to the desk to ask someone. I don't know who he talked to. On 9/17/23 at 2:44 PM, V31 (R322 family member) stated, last week Wednesday I asked a nurse to cut R322's fingernails. R322 is diabetic and if R322 scratches self it could be a bad thing. I don't think they (staff) clean the fingernails. They (staff) brought a pair of clippers in here today and left them, but they did not cut the nails. I don't know if they brought them in here for me to cut R322 nails. On 9/17/23 at 2:50 PM, V32 (Licensed Practical Nurse) stated R322's fingernails are long. If residents' fingernails are too long, they can scratch and injure themselves. To prevent infection, you have to keep…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-20 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to ensure proper use of pressure relieving devices. This failure affected one resident (R322) out of 3 reviewed for air mattress pressure in a sample of 25 residents reviewed. Findings include: On 9/17/23 at 2:45 PM, Observed R322 lying in bed with a low-air-loss mattress. The control panel for the low air loss mattress was set to 230lbs and observed multiple fabric layers between R322 and the mattress. On 9/17/23 at 3:00 PM, V32 (Licensed Practical Nurse) stated I never touch the device (low-air-loss mattress control panel). V32 said the control panel should be set to the resident's weight and there should only be one layer between the resident and the mattress. V32 confirmed on R322's mattress there was a flat sheet, a pad, a second flat sheet folded 2 times (4 layers), R322 was wearing an adult brief and the control panel was set to 230lbs. On 9/17/23 at 3:25 PM, V2 (Director of Nursing) confirmed that R322 was on a low-air-loss mattress with a pump. The pump is set to 230lbs. V2 said the pump is set 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their smoking safety policy, Failed to ensure that smoking materials are not kept by resident at bedside. Failed to ensure that resident was evaluated upon admission for safety of smoking. Failure to ensure that resident was re-evaluated for their ability to smoke safely on readmission, quarterly or annual basis. These failures affected 1 resident (R69) of 5 residents reviewed for smoking in the sample of 25. Findings include: On 09/17/23 at 10:57 AM, R69 stated he keeps his cigars and lighters with him. R69 opened drawer next to the chair R69 was sitting in, reached into drawer, and showed surveyor 1/2 pack labeled Red 2.0 Premium Filtered Cigars and three disposable lighters. On 09/17/23 at 11:19 AM, V2 (Director of Nursing) observed R69's smoking equipment stored in R69's drawer including the three lighters. V2 stated, we didn't know he had those with him and he shouldn't have them in his room and he's on oxygen which is 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-20 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to follow a physician order for fluid restrictions. This failure affected 2 residents (R12, R43) out of 5 reviewed for nutrition care in a sample of 25. Findings include: On 09/17/23 at 12:03 PM, observed water pitcher in R43's room on top of R43's chest of drawers. R43 denies being on a fluid restriction. On 09/17/23 at 12:58 PM, observed R43's meal ticket at lunch. R43's meal ticket did not document that R43 is on a fluid restriction or restrict fluids in any way. R43 received 6-8 ounces hot tea on lunch tray from disposable cup. On 09/17/23 at 12:10 PM, observed the following items on R12's bedside table next to R12's bed: empty water pitcher, one disposable cup 50% filled with apple juice, one disposable cup 75% filled with coffee, small plastic cup 25% filled with water, and empty small plastic cup. Observed sign on R12's wall above R12's bed that documented R12 is on a 1.2-liter Fluid Restriction. On 09/17/23 at 12:48 PM, observed R12 receive lunch tray. R12's meal ticket did not document that R12 is 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to date and change oxygen equipment every 7 days per facility policy and ensure oxygen cannula tubing is placed in a bag when not in use. These failures apply to 1 resident (R69) out of 5 reviewed for oxygen therapy in a sample of 25. Findings include: On 09/17/23 at 10:55 AM, observed R69 sitting in chair at bedside with oxygen concentrator behind him and oxygen tubing attached to the concentrator with oxygen cannula tubing laying on the floor near R69's feet and garbage can. Oxygen concentrator was not in use. On 09/17/23 at 11:06 AM, R69 stated that he uses oxygen everyday and that the oxygen tubing is not changed on a regular basis and was never given any type of container or storage bag to put the nasal cannula tubing in when not in use. R69 stated he drapes the oxygen tubing on top of the oxygen concentrator when oxygen is not in use. R69 stated the oxygen tubing falls on the floor sometimes and that no one does anything about it. On 09/17/23 at 11:09 AM, observed piece of tape wrapped around the oxygen…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-20 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review the facility failed to maintain accurate documentation for 1 resident (R275) of 11 residents who received controlled substances from first floor west unit cart. Findings included: On 9/18/23, at 10:56 AM, during the narcotic reconciliation count with V16 [Registered Nurse], on the west unit cart observed R275's Dronabinol 2.5mg [milligram] take 1 capsule by mouth twice daily dated 9/6/23, with 11 capsules in the card. The count of R275's-controlled substances proof of use form, documents [12] capsules remaining in card. On 9/18/23 V16 stated, I forgot to sign out R275's Dronabinol 2.5mg capsule. I administered R275 the medication this morning around 9 AM. I know to sign out the medication, once I administer the medication, I just forgot to do it. On 9/19/23, V2 [Director of Nursing] stated, My expectation for medication administration is , after the nurse administers medication, they are required to immediately sign out that medication on the appropriate documents. Regarding narcotics, the medication must be signed out 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-20 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the failed to follow their policy and obtain consent for a psychotropic medication for one resident (R63) of five residents reviewed for consents in a sample of 25 residents. Findings include: R63 is an [AGE] year-old individual admitted to the facility on [DATE]. R63's BIMS (Brief Interview for Mental Status), dated 07/02/2023 documents his BIMS as 11/15, indicating R63 has moderately impaired cognition. R63's medical diagnosis includes but not limited to: vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, major depressive disorder, recurrent, unspecified, insomnia, unspecified. On 09/19/2023 at 9:36 am, R63 said when his medication was increased, he was not informed. R63 said he was asked to sign a paper yesterday, 09/18/2023 for his medication. On 09/18/2023 at 1:37 pm, V2 (Director of Nursing-DON) said that a psychotropic consent from the resident or resident representative is needed before 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-20 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and record review, the facility failed to label open insulin vials for 2 residents (R276, R323) reviewed for medication labels on 1 of 6 medication carts. Findings include: On 9/18/22 at 11:00 AM, V16 [Registered Nurse] and surveyor conducted inventory of the first-floor west unit medication cart observed the following: - R276's open vial of Humulin N Insulin 100units/ml, without an open date or expiration date. - R323's open vial of Humalog insulin 100units/ml, without an open date or expiration date. R276's physician order dated 9/13/23 Humulin N Insulin 100unit/ml [Lispro]. R323's physician order dated 9/14/23, Humalog insulin 100units/ml [Insulin Lispro] Inject per slide scale. On 9/18/23 at 11:08 AM, V16 stated, I administered R276's insulin to her this morning. I did not notice there was not a date on the insulin. When the insulin is opened, the nurse should place an open date and expiration date. On 9/19/23 at 5:18 PM, [Director of Nursing] stated, All insulins vials, and pens are to be labeled at the time they are open. The label should…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to CITADEL HEALTHCARE — 14 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.2+0.8 vs chain
Health inspection 4 of 53.5+0.5 vs chain
Staffing 2 of 51.8+0.2 vs chain
Quality measures 4 of 53.4+0.6 vs chain
The other 13 homes this chain runs (chain average 3.2★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
AB INVESTMENT TRUST U/A/D 01/03/23Organization5% OR GREATER DIRECT OWNERSHIP INTEREST10%since 11/01/2020
BERGER, MENACHEMIndividualDIRECT OWNERSHIP INTERESTsince 04/01/2023
GRAF, MARCELLAIndividualDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 11/01/2020
GROSS, SHOSHANAIndividualDIRECT OWNERSHIP INTERESTsince 04/01/2023
PROCTOR, KATHERINEIndividualDIRECT OWNERSHIP INTERESTsince 04/01/2023
RIPSTEIN, KENNETHIndividualDIRECT OWNERSHIP INTERESTsince 04/01/2023
TELLER, CHANANELIndividualDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 04/01/2023
AARON, JONATHANIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 11/01/2020
ESQUIVEL, WILLIAMIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/13/2020
ROBIN, JASONIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2024
ISRAEL, BENJAMINIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/16/2026
STERN, TODDIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/08/2025

CMS files one row per role, so the 17 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$14.5M
Net patient revenuemost recent cost report
+1.9%
Operating marginrevenue minus expenses
$2.1M
Related-party expense15% of expenses
Who pays — share of resident-days
Medicaid 24%Medicare 14%Other / private 62%

This home reported $2.1M paid to related parties — landlords or management companies under common ownership — equal to about 15% 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.

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

$330per resident / day
operating cost
$10,020per month
≈ monthly operating cost
$336per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in IL

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.

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

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145741. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-25, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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