Aliya Of Highwood
50 Pleasant Avenue, Highwood, IL 60040 · For profit - Limited Liability company · 104 certified beds · (847) 432-9142 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- lower-than-typical staff turnover (25% vs 45% nationally) — better care continuity
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 3 actual-harm citations
- a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (2/5)
- about 17% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
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
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 2.9% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.2% | 6.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 99.1% | 54.2% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.8% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 3.0% | 14.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 14.2% | 18.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 96.6% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.2% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 27.7% | 20.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 17.4% | 21.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 2.1% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 40.6% | 63.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 17.6% | 26.1% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 10.0% | 13.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.06 | 2.02 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.12 | 2.22 | 1.80 | 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.
35.0% 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 39 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 79.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 44 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 0.26 therapist hours per resident per day in 2026Q1 — more than 38% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 39% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 35.0%CMS range 23.4–55.2 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.3%CMS range 7.9–16.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 79.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 63.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 50.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 96.4% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.9%CMS range 4.7–14.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.31 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 104 beds and averages 99.0 residents a day — about 95% occupied, or roughly 5 beds typically open. It runs essentially full — expect a waiting list. 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 3.05 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.64 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.86 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 3.01 hrs/resident/day on weekends vs 3.07 on weekdays — 2% thinner on weekends. RN hours go from 0.62 to 0.68 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 25% 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
32 citations, most serious first. The 13 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · Gcited before2026-06-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide personal care in a safe manner and failed to supervise a resident on the patio to prevent a fall for 2 of 3 residents (R2, R3) reviewed for safety and supervision in the sample of 6. This failure resulted in R2 experiencing a fall from her bed on 3/11/26 during cares and sustaining a left femur fracture. The findings include:1. R2's face sheet showed she was admitted to the facility 1/28/2017 with diagnoses to include multiple sclerosis, anxiety disorder, hypertension, bipolar disorder, and paraplegia. R2's 6/9/2026 facility assessment showed she has no cognitive impairment, requires substantial to maximum assist for bed mobility, and is dependent on staff for transfers.R2's care plan initiated 8/20/2018 showed, I require assistance with bed mobility related to paraplegia, multiple sclerosis, osteoporosis, low back pain, cramps, and spasms. Interventions. Provide 1-2-person extensive assist.R2's care plan initiated 3/11/26 showed,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2026-01-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that activities of daily living (ADL) assistance was provided to residents that were dependent on staff assistance for three of 21 residents (R24, R13, R73) reviewed for ADLs in the sample of 21. This failure contributed to R24 obtaining a reddened, excoriated, and painful peri area. The findings include: 1. R24's admission Record shows he was admitted to the facility on [DATE], with diagnoses including hemiplegia, hemiparesis, muscle weakness, cognitive communication deficit, abnormal posture, and heart disease. R24's Minimum Data Set (MDS) dated [DATE], shows R24 has limitations in Range of Motion to both upper and lower extremities. R24 requires substantial/maximal assistance with personal hygiene and is dependent on staff for toileting hygiene. On January 12, 2026, at 11:55 AM, R24 was lying in his bed. There was a large yellow circle noted on the incontinence pad that R24 was laying on. There was a darker yellow circle noted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2023-10-26 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to develop and implement interventions to prevent pressure injuries. The facility also failed to identify two pressure wounds prior to becoming unstageable. This failure resulted in R1 developing two unstageable pressure injuries to her heels. The facility also failed to accurately implement pressure injury prevention interventions for two residents (R3,R4) with pressure injuries. This applies to 3 of 3 residents (R1, R3, R4) reviewed for pressure injuries in the sample of 6. The findings include: 1. R1's admission Record (Face Sheet) showed an original admission date of 5/26/22 with diagnoses to include dementia, Parkinson's disease (a brain disorder that causes a lack of coordination and uncontrollable movements), diabetes type two, weakness, and hypertension (High blood pressure). R1's 7/24/23 Minimum Data Set (MDS) showed she used a wheelchair for mobility. The MDS showed she required extensive assistance of two people for bed mobility (turning from side to side and positioning herself in bed), she required…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-14 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident was provided with a bed suited for his height for one of 21 residents (R24) reviewed for accommodation of needs in the sample of 21.The findings include: R24's admission Record shows he was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis, muscle weakness, cognitive communication deficit, aphasia, and dysphagia. R24's weights and vitals summary shows he is 73 inches long. On January 12, 2026 at 11:55 AM, R24 was observed laying in his bed. The head of his bed was elevated slightly. R24's knees were bent and his left foot was off of the wooden foot end of the bed. R24 said he had a stroke, had back pain and said he could not move his right arm. When R24 was asked if he was comfortable in bed he said he was six feet 2 inches tall and a longer bed would be more comfortable. R24 placed his foot against the wooden foot of the bed to demonstrate if he placed his feet on his bed, his knees…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-14 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure no new recommendations were made after a resident's orthopedic follow up appointment. This applies to 1 of 21 residents (R34) reviewed for quality of care in the sample of 21. The findings include:R34's face sheet lists her diagnoses to include: fracture of left hand and fracture of superior rim of left pubis (pelvic fracture). On 1/13/26 at 10:08 AM, during the morning medication pass, V10 Registered Nurse (RN) was passing R34's medications. R34's husband was also in the room. She observed R34 did not have a cast on her left arm anymore. R34 and her husband both agreed that she had an orthopedic follow up appointment the day before where the cast was removed. V10 RN asked, if they gave her a sling or splint for her arm. R34's husband stated, they gave her a brace and told her to wear it whenever she wanted. V10 RN said ok, she also observed that R34's left wrist was still slightly swollen. R34 had nothing on her left wrist and was not wearing the brace. R34's after visit summary dated 12/8/25 shows, You…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-14 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure R13 and R12 received the minimum necessary treatments and services to promote healing and to prevent infection and to prevent new ulcers from developing for 2 of 4 resident reviewed for pressure ulcers in the sample of 21.The findings include:1.On 01/13/2026 at 10:30AM, R13 was sitting up in a position that placed pressure directly on the coccyx in a reclining chair. R13's left, and right heels were not off loaded and the boney area of the left and right heel was resting directly on the leg rest. At 2:10PM, R13 was sitting up in a position that placed pressure directly on the coccyx in a reclining chair. R13 did not have a pressure reducing pad in the seat of the chair. R13's left, and right heel were not off loaded. R13's left, and right heel was resting directly on the leg rest. On 01/13/2026 at 2:28PM, V7 Wound Nurse pointed to two undated dressing to the left heel and two undated dressing to the right heel and said, R13 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-14 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to address an increase in resident's pain after a urinary catheter change. The facility also failed to ensure a urinary drainage bag was kept below the level of the bladder. This applies to 2 of 6 residents (R55 & R25) reviewed for urinary catheters in the sample of 21. The findings include:1. On 1/12/26 at 10:30 AM, R55 was sitting up in his wheelchair. He stated, he was having a lot of pain in is groin area. The nurse changed his urinary catheter a few days ago and he has been in pain since. He described the pain as feeling like his groin area was on fire and felt no one paid any attention to it. He did state, the facility had given him something for it however it didn't really help the pain, it was still there. R55 had a urinary catheter that was attached to his wheelchair. He stated, he had the urinary catheter because he could not urinate on his own. On 1/13/26 at 1:46 PM, R55 was lying in bed. He stated, he was still in pain in his groin…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-14 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to manage residents' pain for two of 21 residents reviewed for pain management in the sample of 21.The findings include: 1 R24's admission Record shows he was admitted to the facility on [DATE] with diagnoses including hemiplegia, hemiparesis, muscle weakness, abnormalities of gait, cognitive communication deficit, dysphagia, and abnormal posture. R24's Care plan created on December 18, 2025 shows, Pain/Resident will participate in development of a personal pain management program. Resident will receive education related to pain management including non-pharmacological approaches related to medications and recording pain rating. R24's Care Plan initiated January 5, 2026 shows, Pain management as needed. R24's Order Summary Report dated January 13, 2026 shows, an order for acetaminophen 325 mg give two tablets by mouth every four hours as needed for mild pain. On January 12, 2026 at 11:55 AM, R24 was interviewed while he was laying in 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.
- Potential for harm · Dcited before2026-01-14 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure medications ordered by a physician were available. This applies to 1 of 21 residents (R85) reviewed for pharmacy services in the sample of 21. The findings include:On 1/13/26 at 9:51 AM, V10 Registered Nurse (RN) was passing R85's morning medications. R85 had an order for dextromethorphan (cough suppressant) pills. V10 RN could not find the medication in the medication cart. She looked at the order and it showed, the medication was ordered from the pharmacy on 1/7/26. She stated, she would notify the doctor and find out what was going on after medication pass. On 1/14/26 at 11:31 AM, V2 Director of Nursing (DON) stated, the medication is an over the counter (OTC) medication so pharmacy does not send those medications. The facility provides them. The floor nurse that entered the order should have received a message from pharmacy saying they would not deliver the medication. They should have reported that to V2 DON or someone so they could get the medication.R85's January Medication Administration 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.
- Potential for harm · Dcited before2026-01-14 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 a resident's pain patches were stored in a locked compartment and administered by a licensed nurse. This applies to 1 of 21 residents (R28) reviewed for medication storage in the sample of 21. The findings include:On 1/12/26 at 10:07 AM, R28 was lying in bed. There were medication patches lying on her bedside table. She stated, the patches were pain in her knees. She will put them on her knees when she was ready. During the conversation, she placed both patches below each knee. She stated, she always puts them on herself and will remove them later in the day. On 1/13/26 at 1:48 PM, V10 Registered Nurse (RN) stated, R28 puts her own patches on. The nurses give them to her and she does it herself. R28's January medication administration record (MAR) shows two separate orders, Lidocaine external patch 5% (lidocaine), apply to left knee topically in the morning for pain management. Lidocaine external patch 5% (lidocaine), apply to right knee topically for pain management. Both medications are signed out by…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-14 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
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 the menu serving size for the noon meal. This failure resulted in two residents not receiving the planned noon meal. This applies to 2 of 21 residents (R84 and R5) reviewed for dietary services in the sample of 21. The findings include: On 1/12/26 at 12:08 PM, during the noon meal service in the dining room. The noon meal being served was turkey casserole and chopped carrots. Two large steam pans of the turkey casserole dish were at the steam table with a white scoop. V17 (Cook) was plating the noon meal while staff were verbally requesting the type of meal (regular, puree or mechanical). Several staff were in line waiting for a plate, V1 (Administrator) went behind the steam table and began plating . V1 scooped heaping scoop sizes (a mound over the flat of the scoop) of the turkey casserole on the plates. V4 (Dietary Manager) was at the steam table preparing substitute meal requests. The last room cart was being plated by V17. V17 was scrapping the metal tray to fill the scoop and ran out of the turkey…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-14 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
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 R35 with food that accommodated R35's preferences for 1 of 21 residents (R35) reviewed for accommodations of food and drink preferences.The findings include:On 01/12/2026 at 1:02 PM, R37 was lying in bed. The head of the bed was at a 20-degree angle. R37's food tray was on the over bed table. There was an uneaten turkey casserole, uneaten carrots, one 120 milliliters cup of fluid. There was no health shake and no soup. On 01/12/2026 at 1:02PM, R37 stated, every day, every day they send the wrong thing. The facility never serves the food on the menu. I asked for soup, they did not send the soup. I cannot eat this food. On 01/12/2026 at 1:10PM, V19 RN said, dietary will usually send the health shakes up on the cart with the milk. V19 RN checked four dietary carts on the different hallways of the facility. V19 said, the kitchen did not send any health shake to the floor. On 01/12/2026 at 1:20PM, V20 Dietary Manager, looked at R37's dietary sheet and said, oh.well we don't have soup, the health shakes are…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-14 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure staff were wearing PPE (personal protective equipment) in a residents room that is on contact isolation to prevent possible cross contamination. This applies to 1 of 21 residents (R91) reviewed for infection control in the sample of 21. The findings include:On 1/12/26 at 12:51 PM, V17 housekeeping and V19 Certified Nursing Assistant (CNA) were in R91's room. R91's room had a sign on his door that said, Contact isolation. V17 housekeeping was cleaning R91's room. She was only wearing gloves. V19 CNA was helping R91 and taking his dirty laundry out of his room. His laundry was in a yellow cinch bag and not an isolation bag. She carried the laundry out of the room, to the soiled utility room. She did not have any PPE on (gloves or gown). On 1/13/26 at 1:05 PM, V18 ICP (infection control preventionist) Nurse stated, if a resident is on contact isolation staff should wear gloves and a gown when they enter the room. R91 was the only resident on contact isolation in the facility. R91's current order summary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 19 citations
- Potential for harm · E2025-07-02 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents were treated in a dignified manner by other residents and also failed to ensure a resident's dignity by providing the preferred size incontinence briefs. This applies to 8 of 14 residents (R1, R4, R5, R7, R9, R10, R12, R14) reviewed for dignity in the sample of 14. The findings include: R14's Facesheet shows R14 has diagnoses that include, but are not limited to: insomnia, epilepsy, bipolar disorder, and conduction disorder. R14's Care Plan focus, created on 1/6/25 shows R14 has mental illness diagnoses and his care needs include aggression/anger/impulsivity management and psychiatric/mental health. R14's Care Plan also shows R14 may be short-tempered, anxious, easily annoyed. My behavior may include, verbal and socially inappropriate actions. These symptoms may represent feelings of anger, emotional distress, confusion, and insecurity. R14's Minimum Data Set (MDS) Section E dated 6/12/25 shows R14 exhibited verbal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-29 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation interview and record review the facility failed to ensure staff donned all applicable Personal Protective Equipment (PPE) for a resident with Enhanced Barrier Precautions (EBP) and sign was posted indicating EBP for 2 of 3 residents (R2, R1) reviewed for infection control in the sample of 3. The findings include: On 4/29/25 this surveyor was provided a list of residents on Enhance Barrier Precaution (EBP) that included R2 and R1 due to chronic wounds. V2 (Director of Nursing (DON) said all residents that were on EBP have an orange dot by their names outside their rooms and on EBP sign inside the room. 1. On 4/29/25, at 10:10 AM, An orange dot was noted by R2's name outside of his room. V3 (Certified Nursing Assistant-CNA) was in R2's room providing morning care to R2. A sign was noted on R2's head of the bed, Enhance Barrier Precaution. (EBP). R2 was being gotten up from bed. V3 (CNA) applied new incontinent brief, pulled his pants up then V3 transferred R2 from his bed to his wheelchair. V3 (CNA) proceeded to remove R2's soiled linens from the bed and applied…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-11-14 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to double lock the controlled substance box in a medication cart. This applies to 5 of 5 residents (R56, R85, R46, R65, R2) reviewed for medication storage in the sample of 20 and 5 residents (R86, R58, R19, R43, R3) outside the sample. The findings include: The facility provided list of residents with controlled substances in the long term medication cart showed; R56 had morphine (narcotic pain medication); R86 had hydrocodone/acetaminophen (combination narcotic and over-the-counter pain medication); R85 had oxycodone (narcotic pain medication); R46 had zolpidem (prescription sleep medication); R58 had hydrocodone/acetaminophen, methadone (narcotic pain medication), and alprazolam (anti-anxiety medication); R65 had tramadol (narcotic pain medication); R19 had clonazepam (anti-anxiety medication), codeine/acetaminophen (narcotic pain reliever), and methylphenidate (stimulant medication); R43 had tramadol; and R3 had tramadol. Beginning on 11/12/24 at 11:03 AM through 11/12/24 at 11:31 AM, a continuous observation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-14 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure a resident with a reasonable suspicion of mental illness was referred for a Level II PASARR screening for 1 of 1 residents (R2) reviewed for PASARR screening in the sample of 20. The findings include: On 11/13/24 at 10:46 AM, R2 was lying in his bed, watching TV. The surveyor asked R2 how it was going at the facility. R2 replied, Not great, but there's nothing you can do about it. R2 had a flat affect and continued to make negative statements. R2 was alert and oriented and able to express himself. The surveyor asked R2 if he had any specific complaints. R2 looked at the ground and stated, It is what it is. R2 didn't want to speak any further. R2's Facesheet dated 11/14/24 showed diagnoses to include, but not limited to: epilepsy, heart failure; bipolar disorder; and suicidal ideations. This document showed R2 was admitted to the facility 6/21/19. R2's Care Plan initiated 10/26/19 showed R2 is on antipsychotic medications due to bipolar diagnosis. R2's Care Plan initiated 5/20/20 showed he was on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-14 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to assess a new wound and failed to document treatment orders for 1 of 2 residents (R51) reviewed for non-pressure wounds in the sample of 20. The findings include: R51's face sheet printed on 11/14/24 showed diagnoses including but not limited to cellulitis of the left lower limb, lymphedema, morbid obesity, and heart failure. R51's facility assessment dated [DATE] showed moderate cognitive impairment. R51's wound summary report printed on 11/14/24 showed a history of venous stasis wounds to the left lateral and left posterior leg. The same report showed a history of lymphedema to the right leg. On 11/12/24 at 11:38 AM, R51 was seated on the edge of his bed and was wearing shorts. Both lower extremities were wrapped with bandages from just below the knees to the toes. R51 stated he has poor circulation to his lower legs and trouble with fluid build-up. R51 said the staff found a new sore on his right leg yesterday. R51 said he was unsure…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to safely transport a resident in a wheelchair for 1 of 4 residents (R83) in the sample of 20. The findings include: On 11/12/24 at 10:08 AM, R83 was sitting in his wheelchair, at the nurses' station, drawing in a sketch book. V6 (SSD - Social Service Director) asked R83 if he wanted to go participate in activities. V6 stood and pushed R83's wheelchair down the length of the hall to the elevator. R83 did not have foot pedals on his wheelchair. R83 was wearing running shoes. Initially, R83 crossed his ankles and attempted to lift his feet under the wheelchair, with his toes pointing toward the ground. R83's toes hit the ground multiple times, slowing the transport. V6 reminded R83 to lift his feet and stopped. R83 then moved his feet forward, easily lifting the left foot 2 inches off the floor, but was unable to consistently hold his right foot off the ground. R83 put his right foot down multiple times from the middle of the hallway to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-14 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to check placement of a gastrostomy tube (G-tube) prior to performing water flushes for 1 of 1 resident (R35) reviewed for feeding tubes in the sample of 20. The findings include: R35's face sheet printed on 11/14/24 showed diagnoses including but not limited to chronic respiratory failure, cerebral infarction, dysphagia (difficulty swallowing), use of a tracheostomy tube (tube through neck and trachea for breathing) and gastrostomy tube (tube through abdomen to supply liquid nutrition to stomach). R35's facility assessment dated [DATE] showed severe cognitive impairment and staff assistance for all activities of daily living. R35's November 2024 physician orders showed an order start dated 8/21/24 for: Enteral feed order every 4 hours rec (receive) 200 milliliters flush every 4 hours. On 11/13/24 at 2:08 PM, V8 (Registered Nurse) stated R35 receives water flushes through the G-tube every shift and medications via the G-tube. V8 gathered…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-14 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to follow manufacturer instructions regarding the use of an insulin pen. This applies to one resident (R21) reviewed for insulin administration outside the sample of 20. The findings include: R21's admission Record showed he had type II diabetes. R21's Order Summary Report (Physician Order Sheet) showed an active order for 5 units of rapid-acting insulin to be given at meals. In addition to the 5 units of rapid-acting insulin, R21 order sheet showed an order for blood sugar dependent (Sliding Scale) insulin. The order showed 8 units of the same rapid-acting insulin should be given for a blood sugar between 301 and 350. On 11/12/24 at 12:41 PM, V5 Registered Nurse (RN) began preparing R21's rapid acting insulin pen. V5 removed the pen cap, dialed in 2 units of insulin, held the pen horizontally and depressed the injection button. V5 then selected 2 more units, held the pen horizontally, and depressed the injection button. (During this priming process, the needle was not attached.) V5 then attached the needle and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-14 · tag F0807 — failed to offer suitable drinks — isolatedEnsure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
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 water for 1 of 1 residents (R56) reviewed for hydration in the sample of 20. On 11/12/24 at 10:57 AM, R56 was lying in her bed. R56's lips were dry. There was no water cup, water pitcher, or beverages in R56's room. R56 mouth, tongue, and lips were dry. It was difficult to understand what R56 was saying due to her dry mouth. R56 stated, I'm really thirsty. I need water. The surveyor asked R56 if she had something to drink in her room. R56 replied, No, I don't know why they don't leave water in my room. I'm just so thirsty. The surveyor left the room and notified V5 (RN - Registered Nurse) that R56 was thirsty and needed water. At 11:14 AM, V5 (RN) took water to R56's room for medication administration. R56 drank the entire cup of water and stated, I was so thirsty. On 11/13/24 at 10:26 AM, R56 was lying in bed with her eyes closed. There was no water cup, water pitcher, or beverages in R56's room. R56's lips and mouth were dry and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-25 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure wound treatment was provided as ordered for 1 of 3 residents (R3) reviewed for wounds in the sample of 9. The findings include: On 9/24/24 at 11:41 AM, V3, (Wound Care Nurse/Assistant Director of Nursing-ADON), said R3 should have had wound care/dressing change to her coccyx wound on Sunday (9/22/24), as her treatments are ordered every other day. V3 and V4, Certified Nursing Assistant (CNA) positioned R3 on her side to allow V3 to provide her wound care. R3 had a dressing in place on her backside which was dated 9/18. On 9/25/24 at 12:57 PM, V7, (Licensed Practical Nurse), said wound care/dressing changes are done according to the doctor's orders. The facility's Pressure Wounds as of 9/24/24 shows R3 has an active pressure ulcer of her sacrum first identified on 8/8/2023. R3's Order Summary Report dated 9/25/24 shows active treatment orders for cleansing, medication, and a dressing to be completed every other day and as needed to R3's sacral wound. R3's current care plan provided by the facility shows…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-04 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to investigate an allegation of abuse. This applies to 2 of 5 residents (R1 & R4) reviewed for abuse in the sample of 5. The findings include: On August 29, 2024 at 9:30 AM, R1 was sitting up in his wheelchair in his room. He stated, he had a different room mate (R4) that called him a NR. He reported it to V5 Registered Nurse (RN) and called the local police department. The police department came to the facility. They moved R4 out of the room and to a different room. On August 29, 2024 at 10:27 AM, V1 Administrator stated, R1 called the police on R4 for calling him a NR. The police didn't do anything about it and R4 denied ever calling him that. She did not do an abuse investigation because she moved the resident out of the room and didn't treat it as an abuse allegation. On August 29, 2024 at 10:47 AM, R4 was lying in bed watching television. He stated, he was upset that R1 had the television on at 2 AM. R4 called the police pulling…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-14 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure a resident took his medication at the time it was administered by leaving a medication cup at the bedside for 1 of 1 residents (R1) reviewed for medication administration in the sample of four. The findings include: The Face Sheet dated 8/13/24 for R1 showed diagnoses including delusional disorder, major depressive disorder, parkinsonism, cervical disc disorder, spinal stenosis, and history of falling. The Nurse's Note dated 8/9/24 at 8:29 PM, for R1 showed, At 5:00 PM, Writer entered residents room to administer due medications. Resident observed in the restroom and refused administration. At 6:00 PM, Writer entered residents room to re-attempt administration of medication. Resident refused. Reinforcement provided, resident continued to refuse. At 8:30 PM, Writer entered residents room with ADON (Assistant Director of Nursing) to assist with skin assessment, wound treatment and offer medication administration. Resident was observed in the restroom. ADON/Wound nurse offered skin assessment and wound treatment.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-23 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to provide the necessary care and treatment to residents with nonpressure wounds for 2 of 3 residents (R2, R3) reviewed for nonpressure wounds in the sample of 4. The findings include: 1. R2's admission skin and nursing assessments dated 7/14/24 showed R2 was admitted to the facility, from a local hospital, with diagnoses of infectious wounds to her right and left buttock related to a diagnosis of necrotizing fascitis (flesh eating bacterial infection) to both areas. Clusters of wounds were also noted to R2's right and left posterior lower legs. These assessments showed R2 was cognitively intact. R2's wound care notes dated 7/21/24 showed R2's wounds as the following: 1. A left buttock infectious wound measuring 6.5 cm (centimeters) x 16 cm x 0.3 cm. 2. A right buttock infectious wound measuring 10 cm x 28 cm x unknown. 3. A cluster of vascular wounds to R2's left lower leg measuring 15 cm x 17 cm x 0.3 cm. 4. A cluster of venous wounds to R2's right lower leg measuring 22 cm x 20 cm x 0.3 cm. R2's left and right…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-28 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow their grievance policy and failed to ensure a grievance was resolved promptly for 3 of 3 residents (R1, R2, R3) reviewed for grievances in the sample of 8. The findings include: 1. On 3/28/24 at 12:24 PM, R1 was lying in bed with her cell phone in her hand. R1 stated, It's been a long time since all this laundry business started. I will check my emails to give you a better timeline. It's just ridiculous that they lost my clothes and I still haven't been re-imbursed for $56! I provided all the information that was requested, the photos, a receipt and still nothing. It's been very frustrating and I have to keep following up on it. No one here is communicating with me about the hold-up and if I don't keep bringing it up, then they don't do anything. I was missing 3 pieces of clothing in October and it's March now! Still no check and no communication about the hold-up. When I realized the clothes didn't come back from the laundry, I…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-29 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify a resident's responsible party when initiating physician's orders, failed to notify a resident's responsible party regarding room changes, failed to notify a resident's responsible party with positive COVID test results. These failures apply to 1 of 3 residents (R1) reviewed for notification of changes in the sample of 7. The findings include: R1's electronic face sheet printed on 11/29/23 showed R1 has diagnoses including but not limited to Alzheimer's disease, Dementia without behaviors, major depressive orders, and malignant neoplasm of prostate. On 11/29/23 at 10:15 AM, V14 (R1's wife) stated, There have been a lot of things that I have not been notified about recently. My husband's roommate calls me and tells me when he moves rooms or when the doctor has seen him. I don't get the notifications from the facility like I should and I am his legal representative and have the right to know what his condition is and what room he is in. I went 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.
- Potential for harm · E2023-10-19 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and record review the facility failed to include residents during the resident centered care plan meetings. This applies to 4 of 4 (R52, R77, R27, R9) residents in the sample of 19 reviewed for care planning. The findings include: On 10/17/2023 from 11:00AM-12:00PM a meeting was held with R52, R77, R27, and R9 present. On 10/17/2023 at 11:00AM, R27 said she was not being included in her care plan meetings quarterly. On 10/17/2023 at 11:00AM, R52, R77, R9 agreed and said they were not being included in their care plan meetings. On 10/17/2023 at 1:10 PM, V8 Care Plan Coordinator/Restorative/ICP Nurse said care plans are done on a quarterly basis with the interdisciplinary team and the resident or their representative is invited to the care plan meeting. V8 said the care plan meetings are completed in the conference room. R52's Careplan Meeting Invite Letter shows a notification date of 3/1/2023 and a meeting date of 3/3/2023. R77's Careplan Meeting Invite Letter shows a notification date of 4/20/2023 and a meeting date of 4/20/2023. R27's Care Conference document…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-19 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 offer the pneumococcal vaccination after a resident turned [AGE] years of age. This applies to 1 of 5 (R78) residents in the sample of 19 reviewed for immunizations. The findings include: R78's admission Record lists R78 as [AGE] years old male with a birthday of 3/2/1958. On 10/18/2023 at 11:28AM, V2 Director of Nursing (DON) said the facility does not hold the pneumococcal vaccinations onsite they are ordered individually and should be addressed upon admission.V2 said if we are unsure of a residents vaccination status we should investigate it further. V2 said facility staff place the immunization data into the computer charting system based on resident/family interview or hospital records. V2 said she was working on the pneumonia vaccination consents but did not have them completed yet because she was working on influenza consents currently. V2 said there is a flu and pneumonia clinic scheduled at the end of October on the 30th and 31st for residents…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-19 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to administer intravenous medications according to standard of care to 1 of 1 resident (R193) reviewed for medications in the sample of 19. The findings include: R193's Physician Order Sheet (POS) dated 10/23 show R193 has diagnosis of Osteomyelitis of Vertebra. The same POS show R193 has an order of on antibiotic therapy (Cefazolin Sodium Injection Solution Reconstituted 2 gram intravenously (IV) every 8 hours for osteomyelitis (bone infection) until 11/18/2023. R193's progress notes dated 9/28/23 show, (R193) came to the facility from (local hospital) .with PICC line (Peripherally inserted central catheter) to right arm-inserted today 9/28/23 by the hospital. On 10/17/23 at 9:33 AM, R193 was in bed. R193's PICC line to right upper arm intact. R193 had an ongoing IV antibiotics thru his PICC line. The IV was alarming. R 193 said he came with his PICC line due to an antibiotics for bone infection. V4 (License Practical Nurse) entered the room, turned off the IV machine, disconnected the IV tubing from the PICC…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-19 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure as needed (PRN) psychotropic medications had a stop/duration date for 2 of 5 residents (R40, R63) reviewed for psychotropic medications in the sample of 19. The findings include: R40's Physician Order Sheet as of 10/18/23 show R40 has the diagnosis of anxiety. The same document show R40 has an order for Lorazepam 2gm/ml give 0.5 mg every 4 hours as needed (anti-anxiety psychotropic medication) for anxiety, nausea vomiting and restlessness to be given as needed (PRN). There was no stop date or duration for the order. R63'S Physician Order Sheet as of 10/18/23 show R63 had the diagnosis of anxiety. The same document show R63 has an order for Lorazepam (anti-anxiety psychotropic medication) give 0.25 ml by mouth every 4 hours as needed PRN. There was no stop date or duration for the order. On 10/18/23 at 11:20 AM, V2 (Director of Nursing-DON) said both residents (R40 and R63) were both on Hospice and did not have stop dates on the PRN meds but will be working on the stop dates as of this time. The facility policy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to ALIYA HEALTHCARE — 14 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.0 | +2.0 vs chain |
| Health inspection | 3 of 5 | 2.1 | +0.9 vs chain |
| Staffing | 2 of 5 | 1.4 | +0.6 vs chain |
| Quality measures | 5 of 5 | 3.8 | +1.2 vs chain |
The other 13 homes this chain runs (chain average 2.0★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| ALIYA GB HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 03/01/2024 |
| WEINFELD, EFRIAM | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2024 |
| ALIYA OPERATIONS HOLDINGS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2024 |
| ALWAKKAF, AHMAD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2024 |
| WEIMAN, YEHUDA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2024 |
| HIGHLAND PARK NRC REALTY LLC | Organization | ADP OF THE SNF | — | since 03/01/2024 |
CMS files one row per role, so the 11 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.9M paid to related parties — landlords or management companies under common ownership — equal to about 17% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145936. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-14, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.