Warren Barr North Shore

Location & what’s nearby

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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

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.

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

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

57.1% 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 261 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 70.1% 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 97 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 0.21 therapist hours per resident per day in 2026Q1 — more than 25% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% 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.

Staffing

How full it usually is: this home is certified for 215 beds and averages 152.1 residents a day — about 71% occupied, or roughly 63 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.22 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.75 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.77 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 3.15 hrs/resident/day on weekends vs 3.24 on weekdays — 3% thinner on weekends. RN hours go from 0.75 to 0.76 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 27% 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

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

Inspection deficiencies

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

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

29 citations, most serious first. The 14 most serious are shown; the remaining 15 are one tap away and print in full.

• Actual harm · Gcited before2024-11-26 · 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 interview and record review the facility failed to ensure a resident was repositioned safely. This failure resulted in R1 sustaining a intertrochanteric (thigh/femur/hip bone) fracture that required an open reduction surgery. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 12. The findings include: On November 23, 2024 at 1:08 PM, R1 stated, V11 Certified Nursing Assistant (CNA) came to her room to change her multiple times. She refused to have V11 change her because she felt like she was rough with her. She refused to be changed two times. The third time, V11 CNA told her she was going to get changed and threw her legs over the rail and she heard a pop. After that she had pain in her left leg. She stated, she (V11) would not listen to nothing. Told her don't touch me and no, thank you. Now, I have to suffer for my hip fracture and have surgery. I might not be able to walk again. R1 started crying and gave the phone to her daughter (V3). R1's local hospital records dated…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-08-01 · 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 interview and record review the facility failed to provide ongoing assessments for a resident who had an injury of unknown origin on 7/3/24. R1 remained at the facility until he was sent to the emergency room on 7/8/24 for abnormal behavior. This failure resulted in R1 having a mildly impacted and angulated left femoral neck fracture and deep venous thrombosis for 1 of 3 residents reviewed for a change in condition in the sample of 6. The findings include: The Nursing Daily Evaluation dated 7/3/24 for R1 showed R1 was wincing when being changed. The nurse practitioner was notified. An order for an x-ray to both hips was received and completed. The Nurse Practitioner Note dated 7/3/24 at 11:12 AM for R1 showed, R1 seen and examined in his room, per nurses, he has not been at his baseline lately as he is usually seen walking in halls. Per staff, resident noted to be wincing when leg is touched. On exam, resident noted to be rubbing along his left lateral and anterior thigh. He does show some discomfort with palpation to left upper leg. Plan to order x-rays and follow up. 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
• Actual harm · Gcited before2024-03-25 · 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 the facility failed to supervise a resident who was at risk for falls due to history of falls and failed to put specific fall intervention in place to prevent further falls, this failure resulted in R3 sustaining a nasal fracture and left forehead lacerations requiring stitches for 1 of 3 residents reviewed for falls in the sample of 6. The findings include: R3's face sheet show R3 is 76 y/o with diagnoses that include chronic venous hypertension, kidney failure and heart disease. R3's fall risk assessment dated [DATE] shows R3 is HIGH risk for falls. A Facility Reported Incident dated 3/22/24 (initial) show, At 1 pm, NOD (Nurse on duty) responded to a call for help from the room. Resident noted lying face down on then floor with wheelchair behind her. No loss of consciousness. Resident alert and oriented and verbally responsive. Residents states that she dropped something on the floor and wanted to pick it up, but resident unable to recall what item. Rapid response…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-01-24 · 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 a mechanical lift (Hoyer) was used to safely transfer a resident to bed for 1 of 3 residents (R1) reviewed for safety in the sample of 3. This failure resulted in R1 being sent to the hospital with a laceration to her right posterior thigh that required 9 stitches after being transferred with a sit to stand lift. The findings include: R1's Face Sheet shows that she was admitted to the facility on [DATE] with diagnoses of end stage renal disease, lack of coordination, hypotension, dependence on renal dialysis, anemia, abnormalities of gait, abnormal posture and bradycardia. R1's Minimum Data Set assessment dated [DATE] shows that R1 requires substantial/maximal assistance to roll from left to right and is dependent on staff to move from sitting to lying, lying to sitting on side of bed, sit to stand and chair/bed to chair transfers. On 1/24/24 at 10:17 AM, R1 was laying in bed. R1 had a bandage to her right mid-posterior thigh. R1's…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-20 · tag F0659 — isolated
  Provide care by qualified persons according to each resident's written plan of care.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review the facility failed to ensure a qualified staff member operated a resident's enteral feeding pump for 1 of 30 residents (R4) reviewed for qualified persons/staff in the sample of 30.The findings include:R4's admission Record dated 7/24/25 showed R4 was admitted to the facility with diagnoses of respiratory failure and dementia. R4 was admitted with a gastrostomy tube (G-tube) in place for enteral feedings. R4's current care plan showed R4 required enteral feedings as the primary source of nutrition.On 8/18/25 at 10:25 AM, V8 Certified Nursing Assistant (CNA) entered R4's room to provide cares. R4 was in bed with his enteral feeding infusing via an enteral feeding pump at R4's bedside. V8 CNA reached over and paused R4's feeding pump as she began repositioning R4. At 10:29 AM, V8 CNA left R4's room to get additional staff to help provide cares to R4. At 10:38 AM, V8 CNA returned to R4's room and paused R4's enteral feeding pump again to allow V8 CNA and V7 Wound Nurse to provide cares to R4. On 8/19/25 at 11:03 AM, V3 Director of…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-20 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide feeding assistance and incontinence care to residents that require staff assistance to complete these activities of daily living for 3 of 30 residents (R4, R6, R61) reviewed for activities of daily living (ADLs) in the sample of 30. The findings include: 1.R4's admission Record dated 7/24/25 showed R4 was admitted to the facility with diagnoses of respiratory failure and dementia. R4 was admitted with a tracheostomy and gastrostomy in place. R4's current care plan showed R4 was cognitively impaired and completely dependent on staff for all cares, including toileting/incontinence care. On 8/18/25 at 10:01 AM, R4 was in bed. An odor of stool was noted in R4's room. On 8/18/25 at 10:24 AM, R4 remained in bed. An odor of stool remained in R4's room. At 10:25 AM, V8 Certified Nursing Assistant (CNA) was asked when she last did incontinence care on V4. V8 stated she had yet to provide incontinence care to V4 that morning. V8 stated, He…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-20 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide wound treatments to a resident with a pressure injury. The facility failed to provide pressure relieving interventions to residents with pressure injuries and to residents at risk for pressure injuries for 3 of 8 residents (R4, R2, R6) reviewed for pressure injuries in the sample of 30.The findings include:1.R4's admission Record dated 7/24/25 showed R4 was admitted to the facility with diagnoses of respiratory failure and dementia. R4 was admitted with a tracheostomy and gastrostomy in place. R4's Skin and Wound Note dated 8/4/25 showed R4 was admitted to the facility with a Stage 4 pressure injury to his sacrum. The note showed R4's wound currently measured 12.5 cm (centimeters) x 13.9 cm x 3.8 cm. The note showed R4 was incontinent of bowel and bladder. Staff were to provide thorough skin care to R4 after each incontinence episode.A physician order for R4, dated 8/1/25, showed R4 was to have a urinary condom catheter in…

  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 before2025-08-20 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to ensure a urinary catheter bag was maintained below the level of the bladder and failed to apply a condom catheter as ordered to 2 of 11 residents (R42, R4) reviewed for catheters in the sample of 30.The findings include:1. On 8/18/25 at 11:10 AM, R42 was in bed. V12 (Wound NP) and V7 (Wound Nurse) were in the room to perform R42's wound care. R42 was incontinent of stool. V17 and V19 both Certified Nursing Assistants (CNAs) were in the room to provide incontinence care. V19 (CNA) unhooked the catheter and handed the catheter over to V17 who was at the opposite side of the bed. V17 (CNA) then placed the catheter in bed beside R42 at hip level higher than the bladder. Both V17 and V19 then provided incontinence care while the catheter bag kept in bed at hip level. The catheter was half full of urine with urine backflow was noted. After incontinence care, V12 (Wound NP) performed wound assessments showing this surveyor R42's different wounds while catheter was still in bed hip level. On 8/19/25 9:30 AM, V7 Wound…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-20 · tag F0691 — failed to provide colostomy / ostomy care — isolated
  Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
  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 colostomy care to a resident as ordered and as per the resident's preference for 1 of 1 residents (R54) reviewed for colostomy care in the sample of 30. The findings include:R54's admission Record dated 7/9/25 showed R54 was admitted to the facility with a colostomy in place. R54's current care plan showed R54 had a colostomy in place due to an alteration in bowel. The plan showed, Perform ostomy care daily and as needed per physician's order. The plan showed R54 was cognitively intact. A physician order dated 8/9/25 showed R54's colostomy bag was to be changed by staff every 3 days. R54's August 2025 Treatment Administration Record (TAR) showed R54's colostomy bag was changed on 8/9/25. The TAR showed documentation that R54's colostomy bag was changed by V5 Licensed Practical Nurse (LPN) on 8/12/25. The TAR showed documentation that on 8/15/25, R54 refused to have her colostomy bag changed. On 8/18/25 at 9:49 AM, R54 was seated in a chair in her room with colostomy bag intact to her abdomen. R54…

  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 before2025-08-20 · 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 ensure the required volume of enteral feeding was administered for a resident with insidious weight loss for 1 of 8 residents (R10) reviewed for nutrition in the sample of 30. The findings include: R10's face sheet shows she has diagnoses including Alzheimer's Disease, moderate protein-calorie malnutrition, and gastrostomy placement.R10's Enteral Feeding care plan initiated on 7/20/23 shows she requires enteral feedings via a Gastrostomy tube as her sole source of nutrition.R10's Weight Summary shows the following: On 4/3/25 she weighed 121 lbs. Additional monthly weights show she began to have trending weight loss as follows: On 5/4/25 she weighed 119.8, on 6/5/25 she weighed 117.6, on 7/7/25 she weighed 115.8.A Dietary note completed by V11 (Registered Dietician) on 4/3/25 shows that R10 has had weight loss after a desired weight gain. V11's note also shows R10's Jevity 1.5 (enteral feeding) should be increased from a total volume of 560 ml. to a total volume of 630 ml. (milliliters) at a rate of 35 ml. per…

  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 · D2025-08-20 · 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 observation, interview, and record review the facility failed to ensure medications were supervised a resident during medication administration. This applies to 1 of 30 (R26) in the sample of 30 reviewed for medications at the bedside.The findings include:On 8/18/2025 at 9:37AM, R26 had a medication cup on her bedside table in front of her with multiple unknown medications in the cup.On 8/18/2025 at 9:37AM, R26 stated staff leave medications on my table when I'm sleeping.On 8/18/2025 at 9:39AM, V20 Licensed Practical Nurse (LPN) said nurses stay with the residents every time to make sure the resident takes the medication and for safety reasons like choking. V20 said none of her residents can self-administer medications. V20 said she is [R26's] nurse. V20 said she doesn't know where the medications came from, and she didn't pass medications to [R26] yet. V20 said they could be medications from night shift.R26's current Care Plan dated 7/29/2025 doesn't list R26 as being able to self-administer medications.R26's Order Summary Report active orders as of 8/18/2025 does not list…

  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 before2025-06-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure fall interventions were in place for 1 of 3 residents (R1) reviewed for safety in the sample of 3. The findings include: R1's Face Sheet printed on 6/11/25 showed R1 was [AGE] years old and had the diagnosis of lack of coordination and had an abnormal gait. The May 2025 Incident report had R1's name listed with a date of 5/29/25. R1's Progress Note dated 5/29/25 showed R1 had an unwitnessed fall and found next to her bed. R1's Care Plan with a last reviewed date of 5/19/25 showed R1 was at high risk for falls. Listed under interventions was to provide floor mats at bedside. On 6/11/25 at 9:10 AM and 1:26 PM, R1 was in bed. There were no floor mats in place. No floor mats were visible in R1's room. On 6/11/25 at 1:19 PM, V12 (Restorative Nurse) said after a fall occurs, they do an investigation and come up with fall interventions. V12 said the interventions are listed in the care plan. V12 added the care plan interventions should be…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-10-09 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to ensure medications were stored according to manufacturer's guidelines for 4 of 29 residents (R9, R12, R123, R132) reviewed for medications in the sample of 29. The findings include: 1. On 10/08/24 at 9:37 AM, this surveyor with V10 (Licensed Practical Nurse/LPN) opened the locked narcotic box on the first floor dementia unit medication cart. Inside the locked box contained boxes of liquid lorazepam. The boxes shows Store in Refrigerator. R12's box containing liquid lorazepam had a new and unopened bottle with a received date of 7/30/24. R9's box containing liquid lorazepam had an opened, used bottle with approximately 29 ml (milliliters) and had a received date of 8/20/24 and an opened date of 8/30/24. V10 (LPN) said lorazepam should be refrigerated, these boxes of lorazepam have not been kept in refrigerator, they have been stored in the cart. 2. On 10/08/24 at 9:49 AM, this surveyor with V11 (LPN) opened the locked narcotic box of the first floor medication cart. Inside the locked box contained boxes of…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-10-09 · 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 residents were provided comfortable medical equipment for 2 of 29 residents (R99, R24) in the sample of 29. The findings include: 1. On 10/07/24 at 10:04 AM, R99 was in bed finishing breakfast. R99 stated I have my own chair, but it isn't comfortable. They know my chair is uncomfortable, but they say it won't happen when I ask to get another one. On at 10/09/24 at 9:35 AM, V4 (Registered Nurse) said R99 had not mentioned anything to her about her wheelchair, but V6 (Restorative Director) might know about it. V4 said V5 (Central Supply) has wheelchairs and would get her one. V4 said if her wheelchair was uncomfortable, we could get her a new one. On 10/09/24 at 9:39 AM, R99 said she has complained about her wheelchair a number of times to the nurses and aides, and she was told they couldn't do anything until her kids removed her old one. R99 said my feet don't touch the ground in mine so it makes sitting uncomfortable. R99'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.

  Resident Rights 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.

Fines & penalties

$47,317 in federal fines across 3 penalties.

• $22,920 — penalty dated 2026-06-03
• $14,174 — penalty dated 2024-08-01
• $10,223 — penalty dated 2024-03-25

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

Part of a chain

This home belongs to LEGACY HEALTHCARE — 89 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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

CMS files one row per role, so the 26 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.

7 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.

This home reported $2.4M paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

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

What families pay in IL