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Ignite Medical Hanover Park

2000 West Lake Street, Hanover Park, IL 60133 · For profit - Limited Liability company · 150 certified beds · (630) 556-2000 Medicare & Medicaid certified

Call the home — (630) 556-2000 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 25 lower-level deficiencies on record (see below)
Insights

On the public record, this home looks stronger than most — but visit before you decide.

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
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • about 24% 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.

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

Location & what’s nearby

Urgent care / clinic
1601 Tanglewood Ave · (630) 289-7800 · Call to confirm hours
Pharmacy
5500 County Farm Rd · (630) 213-1809 · Call to confirm hours
Grocery
6768 Barrington Rd · (630) 837-1000 · Call to confirm hours
Park
1900 Ontarioville Rd · (630) 823-5700 · 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 5 of 5
Long-stay residentspeople who live here 5 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 5 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 rating5★
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 increased9.2%13.4%15.4%better
Long-stay residents who lose too much weight0.9%6.3%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.9%0.9%better
Long-stay residents with a urinary tract infection0.8%1.5%2.0%better
Long-stay residents with depressive symptoms72.6%54.2%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.4%3.1%3.3%better
Long-stay residents whose ability to walk worsened12.8%14.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication16.7%18.3%18.9%better
Long-stay residents given the seasonal flu vaccine90.0%91.8%95.3%typical
Long-stay residents with pressure ulcers3.2%4.8%4.7%better
Long-stay residents with worsening bladder/bowel control19.9%20.6%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table5.7%21.7%17.1%better
Short-stay residents who newly got an antipsychotic medication1.2%2.2%1.4%better
Short-stay residents given the seasonal flu vaccine88.1%63.1%79.4%better
Short-stay residents rehospitalized after admission22.1%26.1%22.6%typical
Short-stay residents with an outpatient ER visit9.0%13.9%12.0%better

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

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

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

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

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

58.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 515 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

58.2%U.S. median 51.5%
Got home and stayed home
8.9%U.S. median 10.7%
Went back to hospital
68.9%U.S. median 56.6%
Met the expected recovery
0.70U.S. median 0.31
Therapy hours / resident / day
0.38hours / resident / day
Physical therapy
0.27hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 68.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 315 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 0.70 therapist hours per resident per day in 2026Q1 — more than 92% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 30% 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 SNF58.2%CMS range 53.1–62.651.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.9%CMS range 7.0–11.210.7%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 discharge68.9%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 discharge57.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge61.9%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.5%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 stay0.5%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 worsened0.2%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 hospitalization9.2%CMS range 6.9–10.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.111.02Oct 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

1.14
RN hours/ resident / day
0.65
LPN hours/ resident / day
1.58
Aide hours/ resident / day
3.37
Total nurse hours/ resident / day
0.96
RN hoursweekends
28.0%
Total nursing turnover
14.8%
RN turnover

How full it usually is: this home is certified for 150 beds and averages 99.6 residents a day — about 66% occupied, or roughly 50 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.37 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 1.14 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.58 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 3.13 hrs/resident/day on weekends vs 3.46 on weekdays — 9% thinner on weekends. RN hours go from 1.21 to 0.96 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

2
deficiencies at the latest standard inspection (2026-03-05)
8
at the previous standard inspection (2025-04-04)

Deficiencies are fewer than at the previous inspection — improving. 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.

25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.

  • Potential for harm · Ecited before2026-03-05 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure 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 by physician. There were 25 opportunities with five errors resulting in a 20% (percent) error rate. This deficiency affects four (R38, R74, R82 and R88) of 15 residents in the sample of 45 observed during medication pass.Findings include:R88 is a [AGE] year-old, female admitted in the facility on 02/04/26 with diagnoses of Spinal Stenosis, Lumbar Region without Neurogenic Claudication; Gastro-Esophageal Reflux Disease without Esophagitis. POS (Physician Order Sheet) dated 02/04/26 documented Metoclopramide HCl (Hydrochloride) oral tablet 10 mg (milligrams) give 1 tablet by mouth with meals. POS dated 02/14/26 also stated Pantoprazole Sodium oral tablet delayed release 40 mg give 1 tablet by mouth two times a day. On 03/02/26 at 4:20 PM, V5 (Registered nurse, RN) administered Metoclopramide to R88. R88 was not eating her dinner yet at the time Metoclopramide was administered. Pantoprazole was not given to…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-03-05 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to follow their policies related to hand hygiene, hand washing, and use of gloves during medication administration; the facility failed to ensure glucometers were sanitized after use according to manufacturer's guidelines. These deficiencies affected eight (R23, R38, R49, R74, R82, R86, R99, R125) of 15 residents in the sample of 45 reviewed for infection control. Findings include:On 03/02/2026, the following were observed during medication administration:At 4:25 PM, V5 (Registered Nurse/RN) performed an accucheck on R23 using a glucometer. Following accucheck, V5 administered insulin, per orders/parameters. Following insulin administration, V5 hung Daptomycin Reconstituted 500 mg IV (intravenous medication). Gloves remained on following accucheck, insulin administration, and IV hang; V5 returned to the hallway to the medication cart wearing gloves. Glucometer was placed back onto medication cart and was not sanitized following use. At 4:35 PM, V5 had gloves on from medication administration in R23's room 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-04 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to label residents' medications when opened. This applies to 4 out of 4 (R78, R91, R13, and R27) residents reviewed for medications in a sample of 23. The findings include: 1. On 4/01/2025 at 3:50 PM, the facility's third-floor North medication cart was checked with V8 (Licensed Practical Nurse/LPN). R78's Advair and Albuterol inhalers were open and not labeled with open or discarded dates. R91's Trelegy and Breyna inhalers were also open and not labeled with open or discarded dates. V8 checked R78 and R91's inhalers and packages. V8 said the inhalers were open and their open-date labels were unlabeled. R78's Order Summary Report dated 4/02/2025 showed active orders for Advair Diskus Inhalation Aerosol Powder Breath Activate 500-50 MCG/ACT and ALBUTEROL HFA 90 MCG INHALER. 2. R91's Order Summary Report dated 4/02/2025 showed active orders for Trelegy Ellipta Inhalation Aerosol Powder Breath Activate 100-62.5-25 MCG/ACT and Symbicort Aerosol 160-4.5 MCG/ACT (Breyna). 3. On 4/01/2025 at 4:15 PM, the facility's…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-04 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to assess residents to self-administer medications. This applies to 2 of 2 residents (R27, R84) reviewed for self-administration of medications in a sample of 23. The findings include: 1. On April 1, 2025 at 11:19 AM, R27 pulled out an albuterol sulfate inhaler and took a puff of the inhaler as she was short of breath. R27 said she was given the inhaler from the facility. On April 2, 2025 at 12:13 PM, R27 said she had chronic obstructive pulmonary disease, and she used the inhaler twice on April 1, 2025 when she was going to the doctor's office. R27's face sheet showed she was admitted to the facility with diagnoses including chronic obstructive pulmonary disease. R27's POS (Physician Order Sheet) showed an order for Albuterol Sulfate Inhalation Aerosol Powder breath activated 108 (90 base). R27's POS did not show orders for R27 to self-administer medications or to store medications at her bedside. The facility was unable to provide a self-administration assessment. R27's care plan did not show she was able to…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-04 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide 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 utilize assistive devices to prevent furthering worsening of contractures. This applies to 1 of 3 residents (R10) reviewed for restorative care in a sample of 23. The findings include: On 4/01/25 at 10:22 AM, during initial tour, surveyor went to R10's room. R10 was sleeping in bed. Both of R10's hands were contracted. R10 did not have a carrot splint type device used to prevent contractures placed in between her hands. On 4/02/25 at10:14 AM, R10 was in bed, and she did have a carrot in her hands. R10 stated, They never put it on me or give me exercises on my hands. On 4/03/25 at 8:45 AM, R10 was in bed. There was no carrot in her hands. During all three days of the survey, surveyor did not see carrots on R10, on her bedside table, or on her bed. On 4/03/25 at 9:00 AM, V14 (LPN-Licensed Practical Nurse/Restorative Nurse) stated R10 was already contracted when I came in the building. It's almost 3 years since I have been here. The CNA'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-04 · 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

    Based on observation, interview and record review the facility failed to implement safety measure for a resident with a history of falls with injury. This applies to 1 of 3 residents (R294) reviewed for accidents in a sample of 23. Findings include: R294 admitted to the facility from the hospital with a traumatic brain injury. R294's diagnosis includes pneumonia, difficulty walking, lack of coordination, chronic obstructive pulmonary disease, type 2 diabetes, congestive heart failure, hypertension, and kidney failure. On 04/01/25 at 11:55 AM, V19 (Family Member) stated R294 had a fall in the facility on 3/31/25. V19 stated R294 was admitted to the facility from the hospital after suffering a fall at home that resulted in a brain bleed. V19 stated she wished the facility had more safety devices in place to protect R294. V19 stated R294 can communicate, but he does not comprehend well, and his legs are weak. V19 stated the nurse that called her stated he was found on the floor. V19 stated the facility has not put any intervention in place that she can see to protect R294 from falls…

    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 · D2025-04-04 · 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 interview and record review, the facility failed to provide nutritional supplements for a resident who was losing weight. This applies to 1 of 3 residents (R67) reviewed for weight loss in a sample of 23. The findings include: On April 3, 2025 at 11:15 AM, R67 said he did not get the ensure supplement on his meal trays. At 11:28 AM, R67 said he had not gotten his nutritional supplement in the morning. R67 said the nurse must have forgotten. R67 said he had not received his nutritional supplement for more than a month and was not aware he was supposed to have them daily. On April 3, 2025 at 11:20 AM, V15 (LPN/Licensed Practical Nurse) said R67 was losing weight because he was more mobile than when he was first admitted to the facility. V15 said R67 liked the vanilla supplement but sometimes the facility ran out of the flavor R67 preferred. V15 said she had not given R67 his supplement that morning. On April 3, 2025 at 11:34 AM, V5 (RN/Registered Nurse) said she did not remember giving R67 his supplement yesterday. V5 said she used to give him the ensure supplement a long…

    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 · D2025-04-04 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow physician orders and care plan interventions to administer oxygen therapy. The facility also failed to provide humidification with oxygen therapy by using an empty humidifier bottle with oxygen therapy. This applies to 1 of 2 residents (R60) reviewed for respiratory care in a sample of 23. The findings include: R60 is an [AGE] year-old female admitted with an admitting diagnosis, including transient ischemic attack and brain aneurism. On 04/01/25 at 10:14 AM, R60 was observed in her bed with oxygen therapy, a nasal cannula at 5 L/M (Liters/Minute), and an empty humidifier bottle connected to the nasal cannula. On 4/1/25 at 10:14 AM, V11 (Certified Nursing Assistant/CNA) said she would inform the nurse about the empty humidifier. On 4/1/25 at 10:37 AM, V12 (Licensed Practical Nurse/LPN) stated, The oxygen tubing and humidifier bottles need to be replaced every Saturday. The humidifier should be filled up with distilled water. It…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-04 · 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 observation, interview, and record review, the facility failed to reorder residents' prescribed medications. This applies to 3 out of 4 (R15, R27, and R13) reviewed for pharmacy services in a sample of 23. The findings include: 1. On 4/02/2025 at 11:00 AM, V5 (Registered Nurse/RN) was asked to check for the availability of R27's prescribed medications. V5 proceeded to reconcile R27's Order Summary Report with her available prescribed medications. V5 said R27's ordered DuoNeb and Hydrocodone-Acetaminophen medications were not available. R27' Order Summary Report dated 4/02/2025 showed active orders for DuoNeb Solution 0.5-2.5 MG/3ML (Ipratropium-Albuterol) 3 ml inhale orally three times a day and Hydrocodone-Acetaminophen Tablet 5-325 MG Give 1 tablet by mouth every 6 hours as needed for Pain. 2. R15's EMAR (Electronic Medication Administration Record) dated 4/02/2025 showed R15's scheduled 9 AM dose of Flonase nasal spray was omitted. On 4/02/2025 at 11:15 AM, V6 (RN) was asked to check for the availability of R15's prescribed medications. V6 proceeded to reconcile R15's…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-04 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure 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 38 opportunities with 4 errors resulting in a 10.53% error rate. This applies to 3 out of 4 (R15, R90, and R27) residents observed in the medication pass in a sample of 23. Findings include: 1. On 4/02/2025 at 8:00 AM, during R15's scheduled medication administration V6 (Registered Nurse/RN) said she had administered all of R15's medications as ordered. At 10:50 AM, V6 said she did not administer R15's Flonase scheduled at 9 AM because it was unavailable. R15's Order Summary Report dated 4/02/2025 was reconciled and showed an active order for Flonase Suspension 50 MCG/ACT (Fluticasone Proplonate) 1 spray in both nostrils every 12 hours for allergic nasal symptoms. R15's EMAR (Electronic Medication Administration Record) dated 4/02/2025 showed R15's scheduled 9 AM dose of Flonase nasal spray was omitted. 2. On 4/02/2025 at 8:20 AM, during R27's scheduled medication administration V5 (RN) administered Calcium Carbonate 500 mg (milligrams) 1 tablet. V5 then…

    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
Show the remaining 15 citations
  • Potential for harm · Dcited before2024-12-10 · 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 ensure residents were changed in a timely manner for 1 of 9 residents (R3) reviewed for Activities of Daily Living (ADL) in the sample of 9. The findings include: On 12/9/24 at 9:43 AM, R3's call light was alarming. R3 said she needs her wet diaper changed and has been wet all morning. R3 said she was last changed in the early morning around 6:00 AM to 7:00 AM. R3 said her call light was answered once and staff said they would be back to change her, but that was over an hour ago and no one has returned. R3 said she feels very wet and staff never check on her. During this conversation, V6 (Licensed Practical Nurse/LPN) came in and said she would return to change her. On 12/9/24 at 9:53 AM, R3 pushed her call light again and at 9:56 AM, someone said, over the intercom, they would be in to change her. V7 (Certified Nursing Assistant/CNA) arrived to change R3 at 9:58 AM. When V7 removed R3's brief, the brief, the disposable pad, and the cloth…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-10 · 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 implement and/or follow Enhanced Barrier Precautions (EBP) for 3 of 3 residents (R1, R2, R3) reviewed for infection control in the sample of 9. The findings include: On 12/9/24 at 9:22 AM, R2 was sitting on his bed in his room. R2 said he had his toes amputated and they got infected. There was no sign on R2's door, there was no PPE (personal protective equipment) outside of R2's room. On 12/9/24 at 9:43 AM, R3 was lying in bed in her room. R3 said staff do not wear gowns when providing care; I'm not contagious. R3's left lower leg had a long row of staples along a surgical incision. On 12/9/24 at 9:58 AM, V7 (Certified Nursing Assistant/CNA) arrived to R3's room to change her brief. V7 did not wear a gown when she changed R3's brief. On 12/9/24 at 10:10 AM, R1 was lying in his bed watching TV. A dressing/bandage was noted to R1's left lower leg with a small amount of drainage on it. There was no sign on R1's door, there was no PPE outside…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-08-08 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to meet resident ADL (Activities of Daily Living) cares for residents who need assistance with eating and showering. This applies to 5 of 7 residents (R2, R3, R4, R5, and R6) reviewed for ADLs. The findings include: 1. On 8/06/2024 at 10:42 AM, R4 was in bed. R4's breakfast tray was untouched on her bedside tray table. R4's bedside tray table was not within R4's reach and it was positioned parallel to R4's head of bed. R4 said she was really hungry but could not see nor reach her breakfast tray. R4 said she last ate the day prior on 8/05/2024. V2 (Director of Nursing/DON) was alerted to R4's situation and came to R4's room. V2 asked R4 if she was hungry and R4 replied Yes, I'm hungry. V2 proceeded to assist R4 by setting up her breakfast and then prompted her to use her utensils. R4 was observed having difficulty finding her utensils and food items on her tray. Then R4 told V2 her food was really iced cold. V2 said he would get R4 a new…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-08-08 · tag F0755 — failed to provide safe pharmacy services — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to administer and document scheduled medications as ordered for residents. The facility also failed to reorder residents' prescribed medications. This applies to 10 of 14 residents (R1, R9, R10, R11, R14, R15, R16, R17, R18, and R19) reviewed for medication services. The findings include: 1. On 8/07/2024, a continuous observation was done at the second floor nurses' station from 8:00 AM through 9:00 AM. During the continuous observation, V9's (Registered Nurse/RN) medication cart was stationed at the nurses' station and was not in use. At 9:05 AM V9 was asked to be observed for medication administration, V9 said she had already completed her morning med pass. V9 said she was instructed that the facility had a policy for liberalized medication administration. V9 continued to say she believed she was allowed to administer residents' scheduled 9 AM medications from 7 AM through 11 AM. Then V9 was asked to review her assigned residents' EMARs…

    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 before2024-08-08 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to monitor a resident's (R6) blood glucose level as ordered. This applies to 1 of 4 residents (R6) reviewed for quality of care. The findings include: R6's EMR (Electronic Medical Record) showed a diagnosis of type 2 diabetes. R6's MDS (Minimum Data Set) dated 7/11/2024 showed R6 was cognitively intact. R6's Care Plan dated 8/07/2024 showed a focus problem for diabetes with an intervention for blood glucose checks before meals and at bedtime for monitoring. On 8/06/2024 at 10:00 AM, R6 was sitting in her bed, eating breakfast. R6 was Spanish-speaking. R6 said she woke up late and was just now starting to eat her breakfast. At 11:32 AM, V12 (Licensed Practical Nurse/LPN) said she was going to check R6's blood glucose level. V12 proceeded to obtain R6's blood glucose level and said the result was 270 mg/dL (milligrams of glucose per deciliter of blood). R6 tried to explain to V12 that her blood glucose level was high because she just finished eating. V12 said she understood some Spanish and proceeded to record…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-07-31 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to promptly respond to residents' call lights when residents require assistance with ADLs (Activities of Daily Living). This applies to 6 of 6 residents (R4, R9, R10, R12, R13, R14) reviewed for timely call light response and ADL care in the sample of 14. The findings include: 1. On July 25, 2024 at 11:20 AM, R10's call light was illuminated over the doorway of his room. A call light monitoring device similar to a telephone with a display screen, located at the nurse's station, showed all resident room numbers with call lights illuminated on the same unit as R10 resided. The call light monitoring device showed R10's room number and the time of 17 minutes, 26 seconds displayed. As the call light continued to go unanswered, the time continued to increase. No staff answered R10's call light. Upon entering R10's room, R10 was lying in his bed. R10's left foot and lower leg were wrapped in a thick dressing and elastic bandage. R10 had two urinals…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-12 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably 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 a resident's call light was within reach for two residents (R2 and R74) reviewed for accommodation of needs in a sample of 25. Findings include: 1. On 7/9/24 at 11:15 AM, R74 was sitting on the edge of her bed doing exercises with V14 (PTA-Physical Therapy Assistant). Observed that R74's call light is out of her reach. It is hanging over the wooden dividing wall, which is about two feet away from R74's bed. R74 stated, she is not able to call for help as the call light has been hanging over the wooden wall for many days and she cannot reach it. R74's face-sheet showed that R74 is admitted to the facility on [DATE] and her diagnoses includes repeated falls. R74's Minimum Data Set (MDS) assessment dated [DATE] showed that she is cognitively intact, needs limited assist for upper body and substantial assist with lower body activities. Nursing admission evaluation dated 5/31/24 showed that R74 demonstrated the use of call lights…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-12 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide a comfortable, appropriately lit environment for residents. This applies to one resident (R19) reviewed for homelike environment in a sample of 25. The findings include: R19's MDS (Minimum Data Set) dated 2/22/24 shows her cognition is intact. On 7/9/24 at 11:08 AM, R19 said her heating and air conditioning unit and her over bed light have been broken for a couple of months, at least 8 weeks. R19 said she has notified the staff multiple times about her concerns and somebody downstairs at the front desk put the work orders in. R19 said a maintenance man came in and looked at the broken light and said he needed to order a part to fix it but it has not been fixed yet. R19 said she needs the over bed light turned on to be able to read and write because the two table lamps in the room are not bright enough. Surveyor noted at this time the heating and air conditioning unit on the wall was set to 54 degrees but the air blowing out was barely cool and the light switch on the wall when flipped on did not power…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-12 · 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 for level II PASARR (Pre admission Screening and Resident Review) evaluation and determination who was recently diagnosed with newly evident MD (Mental Disorder). This applies to one resident (R38) reviewed for PASARR in a sample of 25. The findings include: R38's Face sheet shows an admission date of 11/25/2019 with primary diagnosis of Type 2 Diabetes Mellitus. R38 had an OBRA (Omnibus Budget Reconciliation Act) screening completed on 10/8/2019 that showed mental illness was not suspected. R38's Face sheet shows a new diagnoses of Psychotic Disorder with Delusions due to known Physiological Condition dated 12/17/2019 and Recurrent Major Depressive Disorder dated 6/25/2021. R38 does not have a diagnoses of Dementia. On 7/9/24 at 10:47 AM, R38 was observed lying in bed, asleep, with her clothes and shoes on. On 7/11/24 at 12:55 AM, V12 (Admissions Director) said PASARR screens are done to make sure the resident is safe to be in a skilled nursing facility and they are receiving all of the services that they…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-12 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to follow professional standards of care while performing blood sugar checks on residents. This applies to two of five residents (R54, R84) reviewed for blood glucose monitoring in a sample of 25. The findings include: 1. On 7/9/24 at 12:09 PM, V6 (RN-Registered Nurse) went to R54's room to do his blood glucose monitoring. V6 wiped R54's right middle finger with alcohol and pricked it with a lancet. Instead of wiping the first drop of blood with a gauze, V6 used an alcohol wipe to clean it. V6 then proceeded to use the second drop of blood to obtain a blood sugar reading of 209 MG/DL (Milligrams/Deciliter). R54's face sheet shows an admission date of 4/20/21. Diagnoses include type 2 diabetes mellitus without complications. R54's POS (Physician Order Sheet) shows an order to do blood glucose monitoring before meals and at bedtime. R54's care plans show he has diabetes mellitus and has blood glucose monitoring done before meals, bedtime and as needed. 2. On 7/9/24 at 12:21 PM, V6 went to R84's room to perform his…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-12 · 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 ensure each resident received adequate supervisvion and assistance to prevent falls. This applies to one residents (R14) reviewed for accident hazards in a sample of 25. Findings include: On 7/9/24 at 11:34 AM, R14 was reclining on her bed. R14 stated she fell earlier in the day. Observed that bed is not in a low position. R14 stated, earlier in the morning, she needed to urinate and so she pulled the call light. R14 stated nobody answered the call light for an hour and she needed to use the bathroom urgently. R14 stated she got up by herself and wheeled herself to the bathroom in her wheelchair. R14 stated, when she stood up to transfer onto the toilet seat, she fell onto the floor and hurt her right hip. R14 stated she still had pain in her right hip. On 7/11/24 at 11:54 AM, V2 (DON-Director of Nursing) stated, all patients must have call lights within their reach. V2 stated, room rounds are done by nursing staff and management staff…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-12 · tag F0697 — failed to manage pain — isolated
    Provide 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 ensure resident's pain was managed. This failure resulted in a resident experiencing pain rated at 10 out of 10. This applies to 1 resident (R28) reviewed for pain management in a sample of 25. Findings include: On 7/9/24 at 12:27 PM, R28 was sitting on her wheelchair in her room. R28 stated she went for over 24 hours without her Percocet pain medication and was in severe pain. R28 stated she was crying with pain and that her pain was over the roof. R28 rated her pain then as a 10 out of a 1-10 scale. R28 stated the nurse had informed her that they were out of her Percocet and were waiting for the pharmacy to deliver it. R28's Minimum Data Set, dated [DATE] showed R28 is cognitively intact. R28's POS (Physician Order Sheet) for July 2024 showed, Percocet Oral Tablet 10-325 MG (Oxycodone/Acetaminophen 10/325)- Give 1 tablet by mouth every 4 hours as needed for severe pain- pain scale of 6-10. R28's Face Sheet showed she was admitted 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-12 · tag F0813 — isolated
    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 observation, interview, and record review, the facility failed to remove expired items from and clean resident refrigerators. This applies to one of one resident (R37) reviewed for personal refrigerators in a sample of 25. The findings include: On 7/9/24 at 10:42 AM, during initial tour, surveyor went to R37's room. Inside R37's refrigerator, the following observations were made: Two (l lb, 8 oz) (pounds/ounces) cartons of vanilla low-fat yogurt had a best by date of 4/19/24; one (1lb, 8 oz) carton of vanilla low-fat yogurt had a best by date of 5/2/24. In two different plastic bags there were slices of ham and cheese. The bags had a foul odor and the cheese had mold on it. On the label, it showed it was packed on 6/19/24. The freezer section of the fridge was dirty and stained. On 7/9/24 at 10:44 AM, R37 stated, The staff check my refrigerator every day. I don't know why those items are still there. I thought they threw it out. If they are expired, then I don't want them. I don't want to get food poisoning. On 7/9/24 at 1:45 PM, V1 (Administrator) stated, It's an all hands 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-05-30 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide toileting hygiene for residents who required assistance with incontinence care. This applies to 4 of 4 residents (R1, R2, R4, R5) reviewed for ADL's (Activities of Daily Living) in the sample of 5. The findings include: 1. On May 28, 2024 at 12:31 PM, V6 (Certified Nursing Assistant/CNA) was providing incontinence care for R2. When R2's gown was lifted, R2 was observed with two incontinence briefs on. V9 (CNA) came to assist V6 with incontinence care, and R2 asked who had entered the room and asked where V9 had been. R2 said he had been waiting a long time to receive incontinence care. R2's MDS dated [DATE] showed R2 was cognitively intact. On May 29, 2024 at 10:59 AM, R2 said it has taken an hour or more for the staff to respond when he needs to be changed. R2 said the staff put two briefs on to avoid his stool from overflowing. On May 28, 2024 at 12:37 PM, V9 said he had last changed R2 before breakfast, around 7:30 AM (five…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-30 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 insulin as ordered. This applies to one of three residents (R1) reviewed for insulin administration in the sample of five. Findings include: R1's EMR (Electronic Medical Record) showed his diagnoses include type 2 diabetes mellitus with diabetic neuropathy and hyperglycemia, congestive heart failure, cardiac pacemaker, hypertension, and chronic kidney disease stage 3. R1's MDS (Minimum Data Set) dated April 26, 2024 showed R1 was cognitively intact. On May 28, 2024 at 10:25 AM, R1 said the nurses give him his insulin after his meals. R1 said the staff do not need to do an accucheck because he has a continuous blood glucose monitor. R1 said the staff give him his food, then come back after he eats, ask him what his blood sugar is, and give him his insulin after he is done eating. R1 said he is supposed to get his insulin before he starts eating. R1 said the staff have not gotten control of his blood glucose, and they were not going to if the insulin was given after the meals. R1's May 2024 Physician…

    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 IGNITE MEDICAL RESORTS — 22 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 5 of 52.7+2.3 vs chain
Health inspection 4 of 52.4+1.6 vs chain
Staffing 3 of 51.9+1.1 vs chain
Quality measures 5 of 54.4+0.6 vs chain
The other 21 homes this chain runs (chain average 2.7★, 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
IGNITE HANOVER PARK JV, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF50%since 06/01/2023
PRESTIGE WORLDWIDE HANOVER PARK LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST10%since 06/01/2023
GOLD PEARL, LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 06/01/2023
CARR, JAREDIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2023
GILLIS, KARENIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2023
GOBST, RYANIndividualINDIRECT OWNERSHIP INTERESTsince 06/01/2023
HAMMOND, AMYIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
JABLONSKI, NICOLEIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2023
MCFARLANE, JOHNIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2023
ROSE, MARCIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2023
THENGIL, MATHEWIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2023
WHITE, JIMIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2023
BERGER, MENACHEMIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 06/01/2023
CARR, BARRYIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2023
FIELDS, TIMOTHYIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2023
ISRAEL, BENJAMINIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 06/01/2023
STERN, TODDIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 06/01/2023
IGNITE TEAM PARTNERS LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2023
SPARK THERAPY LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2023
KURTH, SARAHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/28/2024
SOOD, RAJIVIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2023
BERGER, AVIVAIndividualTRUSTEE OF THE SNFsince 06/01/2023
ISRAEL, YEHUDISIndividualTRUSTEE OF THE SNFsince 06/01/2023
IGNITE HANOVER PARK PROPERTY LLCOrganizationADP OF THE SNFsince 06/01/2023
IGNITE-VILLA HOLDCO LLCOrganizationADP OF THE SNFsince 06/01/2023
LUXE STAFFING LLCOrganizationADP OF THE SNFsince 06/01/2023

CMS files one row per role, so the 54 rows in the source record cover these 26 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$8.9M
Net patient revenuemost recent cost report
+3.6%
Operating marginrevenue minus expenses
$2.0M
Related-party expense24% of expenses
Who pays — share of resident-days
Medicaid 19%Medicare 31%Other / private 50%

This home reported $2.0M paid to related parties — landlords or management companies under common ownership — equal to about 24% 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

$413per resident / day
operating cost
$12,549per month
≈ monthly operating cost
$428per 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 146143. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-05, 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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