Alden Poplar Creek Rehab & Hcc
1545 Barrington Road, Hoffman Estates, IL 60169 · For profit - Corporation · 217 certified beds · (847) 884-0011 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- lower-than-typical staff turnover (28% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has citations for mishandling residents’ money or property (F0568, F0569)
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,281 in federal fines (most recent 2025-07-10)
- its payroll-based staffing rating is low (2/5)
- about 29% 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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 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 improved from 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 3.4% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.5% | 6.3% | 5.4% | typical |
| 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 | 2.6% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 4.9% | 54.2% | 6.5% | better 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 | 2.0% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 4.1% | 14.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 13.8% | 18.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 97.0% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.6% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 22.8% | 20.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.8% | 21.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 2.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 67.8% | 63.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 28.2% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 9.7% | 13.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.66 | 2.02 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.95 | 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.
50.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 261 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 91.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 109 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 0.30 therapist hours per resident per day in 2026Q1 — more than 49% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 43% 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 | 50.6%CMS range 44.1–56.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.7%CMS range 8.0–13.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 91.7% | 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 | 85.3% | 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 | 61.5% | 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 | 99.5% | 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 | 66.7% | 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 | 94.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.6% | 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 | 1.1% | 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 | 8.1%CMS range 5.3–11.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.99 | 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 217 beds and averages 168.7 residents a day — about 78% occupied, or roughly 48 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 2.82 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.73 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.57 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.52 hrs/resident/day on weekends vs 2.94 on weekdays — 14% thinner on weekends. RN hours go from 0.76 to 0.64 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 28% is below the national median of 45%. 1 administrator has left in the past year.
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.
29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.
- Immediate jeopardy · Jcited before2025-07-10 · 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 ensure a resident with severe cognitive impairment and a history of wandering was supervised to prevent elopement. This failure resulted in R1 eloping from a secured memory care unit, exiting the building without staff identifying and preventing R1 from eloping. R1 exited the building and ambulated without her walker crossing a six-lane busy intersection and was found approximately 0.8 miles away from the facility wandering outside of the local grocery store. This applies to 1 of 6 residents (R1) reviewed for safety in the sample of 6. The Immediate Jeopardy began on 7/1/25, when R1 got on the elevators with another resident's family on the secured memory unit. R1 exited the first-floor elevators and ambulated out the front entrance without staff identifying R1 was eloping the facility. R1 exited the building and ambulated without her walker crossing a six-lane busy intersection and was found approximately 0.8 miles away from the facility…
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 before2026-03-11 · 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 ensure no delay in care and treatment to a resident with unwitnessed fall that was later diagnosed with fractured left elbow. The facility also failed to revise resident comprehensive care plan in a timely manner for cast management and ADLs (Activity of daily living) limitation affected by cast on left elbow due to fracture. This deficiency affects one (R1) of three residents reviewed for Fall management.Findings include: On 3/11/26 at 10:05AM, V5, Family member, said R1 reported she fell backward in her room on 2/21/26 sometime between 1:30PM to 8:30PM. R1 complained of left elbow pain with limited mobility and swelling. X-ray of elbow was not done until the following evening, 2/22/26. V5 said V6, RN (Registered Nurse), called him around 9:00PM to inform him the x-ray result indicated a fracture of the left elbow. R1 was sent to the hospital emergency room (ER) for further evaluation as ordered by physician. V6 informed him there will…
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 · F2025-12-04 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed properly store food in a manner to prevent cross-contamination and failed to label prepared foods stored in the refrigerator. This applies to all residents residing in the facility.The findings include:The CMS 671 form, dated 12/2/25, showed there were 164 residents residing in the facility.On 12/2/25 at 9:40 AM, there was a cardboard box of cornflakes on the floor of the dry storage room. The surveyor showed V10 (Hostess/Assistant Supervisor) the box and asked if food should be stored on the floor. V10 replied, No that shouldn't be on the floor because the floor may be dirty and there is a risk of cross contamination. At 9:43 AM, there were two boxes of food (1 with elote and another with baguettes) on the floor of the left side of the freezer. The boxes were frozen to the floor of the freezer. On the right side there was a box of unknown food and a black plastic bag on the floor of the freezer. The surveyor asked V10 what was in the box. V10 attempted to pull the box out from under the shelving but was unable…
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 before2025-12-04 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to notify a resident's provider of elevated blood glucose levels. This applies to 1 of 1 residents (R34) reviewed for notification in the sample of 45. The findings include:R34's admission Record (Face Sheet) showed a current admission date of 11/9/24, with diagnoses to include but not limited to, diabetes type2, heart failure, and atrial fibrillation (rapid, irregular heartbeat). R34's Order Summary Report (physician orders) showed an order for rapid acting insulin before meals. The order shows the amount of insulin to be given is dependent upon R34's blood sugar value. The order shows if R34's blood sugar is greater than 350, then the nurse should give 10 units of rapid acting insulin and call the provider. (All blood sugar values are in milligrams per deciliter.) R34's October 2025 Medication Administration Record (MAR) showed on 10/1/25 a blood sugar of 378 prior to his evening meal. The MAR showed a value of 351 on 10/3/25 prior to his noon meal. The MAR showed a value of 359 on 10/12/25 prior to his evening meal. R34's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-04 · 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 care was provided in a manner to prevent contamination of the wound bed for 1 of 8 residents (R144) reviewed for pressure injuries in the sample of 45.The findings include:R144's admission Record showed diagnoses including, but not limited to, hemiplegia and hemiparesis following a cerebral infarction affecting his left non-dominant side, a stage IV pressure ulcer of left heel, muscle spasms, and pain in his left foot. R144's care plan initiated on 5/2/2025 showed he has an actual alteration in skin integrity as evidenced by an abrasion to his left anterior ankle and a pressure injury to his left heel. R144's Order Summary Report showed an active order to clean the abrasion to his left anterior ankle, apply (a dressing designed to maintain moisture to the wound bed), and cover with a foam dressing. The report also showed an active order to cleanse R144's left heel with saline, paint with betadine, apply (dressing designed to maintain moisture to the wound bed), and cover with a foam dressing.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-04 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an ordered treatment for contractures. This applies to 1 of 1 residents (R89) reviewed for range of motion in the sample of 45. The findings include:R89's admission Record (Face Sheet) showed he was admitted to the facility on [DATE], with diagnoses to include but not limited to, paralysis to his right side due to a stroke, dementia, and nerve pain. R89's 10/30/25 Quarterly Minimum Data Set (MDS) showed he had severe cognitive impairment. R89's Order Summary Report (Physician Order Sheet, POS; as of 12/4/25) showed an order started on 9/10/24 for [cotton gauze wrap] to right hand during the day and off at night, can remove for skin checks. On 12/04/2025 at 9:49 AM, R89's right hand appeared contracted. R89 did not have a (cotton gauze) wrap in or around his right hand. On 12/04/2025 at 9:57 AM, V6, Licensed Practical Nurse (LPN), stated she has provided care for R89. V6 stated she believed the order was not a wound dressing, but a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to transfer a resident in a safe manner. This applies to one two (R136) reviewed for safety in the sample of 45.The findings include: The facility face sheet for R136 shows she has diagnoses to include vascular dementia, congestive heart failure, morbid obesity and history of falls. The facility assessment for R136, dated 10/30/2025, shows she has moderate cognitive impairment and requires touching assistance from staff with toilet transfers. The care plan for R136, dated 8/19/2024, shows she has poor safety awareness and poor endurance and an intervention to use a gait belt for transfers and ambulation was in place.On 12/2/2025 at 10:21 AM, R136 was being assisted to the toilet by V7, CNA (Certified Nursing Assistant). V7 pushed R136 up to the toilet and told her to stand up. V7 was using the back of R136's pants to help stabilize R136 as she stood and pivoted to the toilet. When R136 was finished using the toilet, V7 told R136 to stand up and she would clean her up. As R136 was standing and V7 was cleaning…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-04 · 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
Based on observation, interview, and record review, the facility failed to address a recommendation by the Registered Dietitian to increase a resident's enteral feeding for 1 of 4 residents (R5) reviewed for tube feedings in the sample of 45. The findings include: R5's admission Record, provided by the facility on 12/4/2025, showed diagnoses including, but not limited to adult failure to thrive, severe protein-calorie malnutrition, encounter for attention to gastrostomy (feeding tube), memory deficit following cerebrovascular disease, adjustment disorder, epilepsy, depression, and aphasia following cerebral infarction (a language disorder caused by brain damage-often from a stroke, injury, or tumor-that impairs speaking, understanding speech, reading, and writing). On 12/2/2025 at 11:32 AM, R5 was lying in bed. The head of R5's bed was up 45 degrees. No signs of distress were noted. A feeding delivery system was next to R5's bed, not running. Supplies for R5's tube feedings were in her room. A review of R5's electronic medical record showed current orders for enteral feedings of 960…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-04 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure physician orders were followed for the administration of oxygen for 1 of 1 resident (R122) reviewed for oxygen services in the sample of 45.The findings include:R122's face sheet showed she was admitted to the facility 10/8/25, with diagnoses to include chronic kidney disease, chronic respiratory failure, chronic congestive heart failure, hypertensive heart disease, muscle weakness, depression, and dependence on supplemental oxygen. R122's facility assessment, dated 10/15/25, showed she has mild cognitive deficit and requires assistance with transfers. R122's December 2025 Physician Order Sheet showed, Respiratory: Oxygen per nasal cannula at 2 liters per minute continuous. R122's care plan, initiated 10/21/25, showed, [R122] requires oxygen therapy; Continuous in Dx of Chronic Respiratory Failure, unspecified whether with hypoxia or hypercapnia. Interventions/Tasks. Adjust oxygen to maintain saturation within adequate parameters. R1's vital signs record for the morning of 12/4/25 showed R1's oxygen…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-04 · 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 remove soiled gloves before touching any other clean surfaces. This applies to one of Six residents (R136) reviewed for infection control in the sample of 45.The findings include:On 12/2/2025 at 10:21 AM, R136 was being assisted to the toilet by V7, CNA (Certified Nursing Assistant). R136 had been incontinent of stool and V7 was cleaning her up standing in the bathroom. V7 wiped R136 and cleaned her skin of stool. V7 never removed her soiled gloves and then pulled up R136's pants and rubbed R136's back to comfort her. The facility face sheet for R136 shows she has diagnoses to include vascular dementia, congestive heart failure, morbid obesity and history of falls. The facility assessment for R136, dated 10/30/2025, shows she has moderate cognitive impairment and requires touching assistance from staff with toilet transfers and toileting hygiene.On 12/4/2025 at 10:47 AM, V8, CNA, said gloves should be changed when they become soiled and the hands should be cleaned before putting on clean gloves.On 12/4/2025…
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 · D2024-11-06 · tag F0551 — isolatedGive the resident's representative the ability to exercise the resident's rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to honor the decisions of a hospice resident's health care Power of Attorney for 1 of 3 residents reviewed for rights exercised by a resident's representative in the sample of 3. The findings include: R1's facility care plan, dated 8/13/24, showed R1 was under hospice care due to her diagnoses of senile degeneration of the brain, cerebral atherosclerosis, and dementia. R1 was severely cognitively impaired and dependent on staff for cares. The plan showed, Coordinate care and services between facility caregivers and hospice company to ensure all resident needs are met . Obtain advanced care planning wishes of patient and family and incorporate them into the plan of care . R1's Power of Attorney for Health Care form, dated 11/23/2018, showed V10 (Family of R1) was R1's healthcare Power of Attorney (POA). The form showed R1 authorized V10 to make decisions for R1 when R1 could no longer make decisions for herself. The form showed R1 did not want any treatment to prolong her life, but wanted treatment to ensure comfort and no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 18 citations
- Potential for harm · Dcited before2024-11-06 · 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 interview and record review, the facility failed to designate a staff member, or implement a process, to ensure effective, ongoing communication and collaboration between the facility, a hospice resident's Power of Attorney for health care (POA), and the hospice provider. The facility failed to ensure facility staff had access to and reviewed a resident's hospice plan of care and hospice progress notes. These failures apply to 1 of 3 residents (R1) reviewed for care and services of a hospice resident in the sample of 3. The findings include: R1's facility care plan, dated 8/13/24, showed R1 was under hospice care due to her diagnoses of senile degeneration of the brain, cerebral atherosclerosis, and dementia. R1 was severely cognitively impaired and dependent on staff for cares. The plan showed, Coordinate care and services between facility caregivers and hospice company to ensure all resident needs are met . Obtain advanced care planning wishes of patient and family and incorporate them into the plan of care . R1's Power of Attorney for Health Care form, dated 11/23/2018,…
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 · D2024-09-11 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 signed Physician Orders for Life-Sustaining Treatment (POLST) form was followed up with and signed by the physician. This applies to 1 of 28 residents (R96) reviewed for Advanced Directives in the sample if 28. The findings include: R96's Facesheet, dated 9/10/24, shows R96 has a current advance directive of Full Code. R96's Facesheet also shows V13 (R96's Family Member) is R96's Healthcare Surrogate. On 9/10/24 at 10:50 AM, R96 said someone from the facility spoke with him and V13 about changing his Advanced Directive information approximately two to three weeks ago. R96 could not recall who they spoke with. R96 said his current wishes are to continue with finalizing his Do Not Resuscitate (DNR) status, stating he has been through enough already. R96's Social Service Quarterly Assessment, dated 8/14/24, completed by V12 (Corporate Social Services) states, Wife (V13) expressed interest in completing a POLST form. Wife requested copy of 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 · D2024-09-11 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to follow its abuse policy by reporting and investigating allegations of sexual abuse. This applies to 2 of 28 residents (R56 & R115) reviewed for abuse in the sample of 28. The findings include: On September 10, 2024 at 1:30 PM, R56 stated R115 touched her inappropriately last summer. She was out on the patio and R115 came out there. She told V14 (Social Worker), who no longer works at the facility. V14 told her she would take care of it. On September 11, 2024 at 9:26 AM, V1 (Administrator) stated R56's allegation of abuse were not reported to her, and she has not done any abuse investigation. The facility's abuse policy, dated September 2020, shows, Policy: This facility affirms the right of our residents to be free form abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility will report reasonable suspicion of a crime. This facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident…
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 before2024-09-11 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to ensure staff reported allegations of sexual abuse to the Administrator immediately. This applies to 2 of 28 residents (R56 & R115) reviewed for abuse in the sample of 28. The findings include: On September 10, 2024 at 1:30 PM, R56 stated R115 touched her inappropriately last summer. She told V14 (Social Worker), who no longer works at the facility. On September 11, 2024 at 9:26 AM, V1 (Administrator) stated V14 (Social Worker) never reported to V1 (Administrator), who is the abuse coordinator. V1 stated allegations of abuse should be reported to her. R115's care plan, dated July 29, 2024, shows, (R115) demonstrates socially inappropriate behaviors as evidenced by attempting to/actually touching females in the facility. R56's and R115's electronic medical records do not show any documentation regarding the incident.
- Potential for harm · D2024-09-11 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to investigate an allegation of sexual abuse. This applies to 2 of 28 residents (R56 & R115) reviewed for abuse in the sample of 28. The findings include: On September 10, 2024 at 1:30 PM, R56 stated R115 touched her inappropriately last summer. She was out on the patio and R115 came out there. R115 came over to R56 and grabbed her breast. She asked him to stop and then continued to go down her shirt and up her shirt touching her breast again. She told V14 (Social Worker), who no longer works at the facility. V14 told her she would take care of it. On September 11, 2024 at 9:26 AM, V1 (Administrator) stated she spoke with R56 the night before. R56 refreshed her memory and reminded her of the situation on the patio. R56 did inform V14 (Social Worker) that R115 touched her blouse in the breast area. V14 (Social Worker) never reported it to V1 (Administrator), who is the abuse coordinator. V1 (Administrator) stated she did not do any investigation into R56's allegation that R115 touched her breast on the patio last summer. If it…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-11 · 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 revie,w the facility failed to ensure schedule II controlled substances were stored in a separately locked compartment for 2 of 28 residents (R54 and R92) reviewed for medication storage in the sample of 28. The findings include: 1. R54's Physician's Order Sheet, printed on 9/10/24, shows an order for Hydromorphone solution (Schedule II controlled substance) 4 milligrams/milliliter (mg/ml) to be given as needed for pain or shortness of breath. On 9/9/24 at 10:17 AM, there was a bottle of R54's Hydromorphone in the refrigerator that was located in the medication room on the second floor. The refrigerator had a lock located on the side of it, but the lock was not locked. 2. R92's Physician's Order Sheet, printed on 9/10/24, shows an order for Hydromorphone solution (Schedule II controlled substance) 4mg/ml to be given as needed for pain or shortness of breath. On 9/9/24 at 10:17 AM, there was a bottle of R92's Hydromorphone in the refrigerator that was located in the medication room on the second floor. The refrigerator had a lock located 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 before2024-09-11 · 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 personal protective equipment (PPE) was worn when providing care to a resident on enhanced barrier precautions (EBP) for 1 of 28 residents (R78) reviewed for infection control in the sample of 28. The findings include: R78's Physician's Order sheet shows an active order, dated 12/28/22, for, EBP for Device Care or Use of Feeding Tube. R78's Care Plan shows she requires tube feeding and stoma site care and has an intervention of: Enhanced Barrier Precautions will be implemented during high contact resident care activities. On 9/9/24 at 10:21 AM, there was a sign on R78's door showing she was on EBP. V4 and V5 (Certified Nursing Assistants) went into R78's room and provided incontinence care to R78 and changed her bedding. V4 and V5 did not have a gown on while providing the care. On 9/10/24 at 2:01 PM, V9 (Infection Preventionist) said residents on tube feeding should be on EBP. V9 said staff should wear PPE (gloves and gown) anytime they are going to be providing care to the resident. The facility's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-11 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop 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 ensure a resident received an influenza vaccine following admission to the facility. The facility also failed to ensure a resident was offered a second pneumonia vaccine. This applies to 2 of 5 residents (R116, R90) reviewed for immunizations in the sample of 28. The findings include: 1. R116's Face Sheet current Face Sheet shows she was last admitted to the facility on [DATE]. R116's Informed Consent Influenza Immunization Vaccine 2023-2024 shows the box marked for Unless medically contraindicated, I give the facility permission to administer the influenza immunization vaccine. The back of this same form shows: Legal Representative Signature: (Typed R116's son's name), and dated 10/25/23. On 9/11/24 at 12:44 PM, V9 (Infection Preventionist) stated, I followed up with the son and he refused the vaccine- the nurse did the consent, but then the son refused. V9 was asked where this was documented, and V9 stated she just put refused on the immunization…
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 before2024-08-26 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure allegations of sexual abuse were reported to the police for 1 of 3 residents (R1) reviewed for sexual abuse in the sample of 4. The findings include: On 8/26/24 at 9:41 AM, R1 said V5 (Certified Nursing Assistant/CNA), was behind the curtains and touched her breast. R1 said she told a nurse and a Social Worker about the incident. R1 said no one has followed up with her about the incident to investigate or communicate a plan. R1 did not provide any other details about the incident and reported seeing V5 in the facility, but said he does not come near her. R1 said she feels nervous sometimes when she sees V5. On 8/26/24 at 11:12 AM, V1 (Administrator) said V2 (Assistant Administrator) did the investigation into the sexual abuse allegations from R1 against V5. V1 said she does not know if the police were informed of the allegations. On 8/26/24 at 11:33 AM, V2 said they did not file a police report because R1's sister did not want them to. On 8/26/24 at 11:58 AM, V3 (Director of Nursing) said he did not notify 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 · D2024-08-12 · tag F0569 — isolatedNotify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to release a resident's trust funds after discharge for 1 of 3 residents (R1) reviewed for trust funds in the sample of 3. The findings include: R1's Face Sheet, dated 8/12/24, shows R1 was discharged from the facility on 3/10/24. On 8/12/24 at 10:54 AM, V1, Administrator, said, When a resident discharges, any money remaining in the trust fund after all bills have been paid, is returned to the resident or to the resident's Power of Attorney (POA). (V3, Director of Financial Service) at the corporate office sends out the resident funds. On 8/12/24 at 10:35 AM, V2, Business Office Manager, said she didn't recall any concerns with R1's trust fund or speaking to R1's family or R1's new facility about it. On 8/12/24 at 11:58 AM, V3 said R1 discharged from the facility on 3/10/24, and R1's remaining balance was sent to another facility in two checks. V3 said, The first check for $5288.14 was dated 4/15/24 (36 days after discharge), and as of today shows that it wasn't cashed, and the second check was sent 4/18/24 (39 days after…
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 before2024-06-06 · 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 ensure a residents' care provider was notified after a resident received a Defebrilator Vest (DV) intervention (shock) which applies to 1 of 1 residents reviewed for physician notification in a sample of 3. The findings include: R1's face sheet, printed on 6/3/24, showed R1 is an [AGE] year old man admitted to the facility on [DATE], with diagnoses which include: acute on chronic (congestive) heart failure and rheumatic mitral (valve) insufficiency. On 6/3/24 at 10:30 AM, when asked if the defibrilator vest (DV) ever went off, R1 stated, Yes! R1 stated he was shocked by the vest about a week ago, right here (pointed to bed). R1 stated, It felt like I got shot by a rifle. R1 stated his pillow had some blue stuff on it. R1 then restated, It was like a shot to the chest. R1 stated one of the girls came in and went to go get the nurse. R1 stated a nurse came into his room. R1does not remember the nurse's name, but it was a man. After the nurse left, 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 · D2024-06-06 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility neglected to identify R1 had a defibrillator vest (DV), and failed to ensure facility staff were trained on the DV's set up, monitoring, functioning, and trouble shooting of the device which applies to 1 of 1 residents (R1) reviewed for neglect in a sample of 3. The findings include: R1's medical record showed R1 was admitted to the facility on [DATE], with diagnoses which included: acute on chronic (congestive) heart failure and rheumatic mitral (valve) insufficiency. On 6/3/24 at 10:30 AM, R1 was in his room wearing the DV. R1 stated he got it at the hospital, and it came with him to here (pointed at bed). R1's facility referral, dated 5/22/24, showed the referral was sent to the facility's Central Intake and reviewed on 5/21/24. R1's referral has multiple entries (8) of R1 utilizing the DV during R1's hospital admission, and to be used until R1 was able to have an outpatient Angiogram after discharge. On 6/4/24 at 11:10 AM, V21, Admissions…
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 before2024-06-06 · 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 to ensure a resident had ongoing monitoring after a Defibrillator Vest (DV) treatment (shock) was delivered, and failed to ensure a DV hotspot was set up to assist with remote monitoring which applies to 1 of 1 residents (R1) reviewed for quality of care in a sample of 3. The findings include: R1's face sheet, printed on 6/3/24, showed R1 is an [AGE] year old man admitted to the facility on [DATE], with diagnoses which include: acute on chronic (congestive) heart failure and rheumatic mitral (valve) insufficiency. R1's Careplan, printed on 6/3/24, showed no entries referencing R1's DV. On 6/3/24 at 10:30 AM, R1 was in bed wearing the DV. R1 stated he started wearing the DV in the hospital and it followed him here. When asked if the vest ever worked, R1 stated yes. R1 stated he was shocked by the vest about a week ago right here (pointed to bed). R1 stated, It felt like I got shot by a rifle. After that there was some blue stuff on my neck 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 · D2024-04-26 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to respect a resident's personal space when a staff member stored their bag in the resident's closet. This applies to 1 of 3 (R7) residents rights reviewed for staff behavior in the sample of 7. The findings include: R7's admission Record (Face Sheet) showed an original admission date of 8/14/21, with diagnoses to include heart failure, dementia, and psychosis. R7's 2/16/24 Quarterly Minimum Data Set (MDS) showed she was experiencing severe cognitive impairment, with a brief interview for mental status score of 5 out of 15. On 4/24/24 at 10:20 AM, V15, R7's Daughter, stated she was visiting her mother the evening of 4/20/24 (Saturday). V15 stated as she was leaving R7's room, she opened her closet door to ensure R7's clothing was clean and organized. V17 said she noted a bulge of clothing on the bottom of the closet. V17 stated the bulge was a backpack covered with R7's clothing. V17 stated the bag had a bottle of the same perfume her mother wore, so she believed the bag was brought in and left by a family member. V17 grabbed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-26 · 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
Based on observation, interview, and record review, the facility failed to safely transport a resident in a manner to prevent him from falling out of the wheelchair. This applies to 1 of 4 residents (R6) reviewed for falls in the sample of 7. The findings include: R6's admission Record (Face Sheet) showed an original admission date of 4/4/24, with diagnoses to include blood infection, dialysis, and epilepsy. R6's 4/20/24 Discharge Minimum Data Set showed he was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. R6's 4/20/24 Nurse Note from 12:10 AM showed he was being discharged home with his wife. R6's 4/20/24 Progress Note from 12:20 AM showed, As CNA (Certified Nursing Assistant) was pushing [R6]'s wheelchair out to the lobby and went over a small bump by the door, [R6] slipped off his wheelchair and fell forward on his knees and his face. Assessed and noted nose bleeding and cut on his lower lip .denies any pain and discomfort . The note showed R6 was sent to the local Emergency Department for evaluation. (The progress note was authored 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 · E2023-10-04 · tag F0568 — patternProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
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 residents received a quarterly statement of their monthly Social Security stipend for five of five residents (R5, R28, R44, R81, R102) reviewed for Personal Funds in the sample of 26. The findings include: On 10/02/23 at 9:39 AM, R44 said, The person on the first floor that handles the resident's money never answers the phone. The first person would come around and ask if I needed any money, the new lady is hard to get to. If I wanted to get a couple of dollars I would have to wait for my son. On 10/03/23 at 2:17 PM, V14, Business Office Manager, said, I do not send out quarterly statements to the residents. I give the resident their balance when they make a withdrawl. Residents are the only ones that have access to their accounts. On 10/04/23 at 9:05AM, R81 said, I do not get quarterly statements. On 10/04/23 at 9:12 AM, R102 said, I think it started in November 2022. I have asked twice for a statement regarding the balance of my funds; no one has given me one. I have no idea how much money I have in my account. 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 · D2023-10-04 · 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
Based on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) assistance for residents that are totally dependent on staff for toileting/incontinence care for 2 of 26 residents (R103, R82) reviewed for ADLs in the sample of 26. The findings include: 1. R82's resident assessment, dated 7/19/23, showed R82 was totally dependent on staff for toileting/incontinence care. The assessment showed R82 was always incontinent of urine and stool. On 10/2/23 at 10:38 AM, R82 was seated in her wheelchair in the second-floor dining room. R82 stated staff last provided her with incontinence care at 9:00 AM. On 10/2/23 at 11:01 AM, R82 remained seated in her wheelchair in the second-floor dining room. On 10/2/23 at 11:35 AM, R82 remained seated in her wheelchair in the therapy room. On 10/2/23 at 12:09 PM, R82 returned to the second floor, from therapy. R82 remained in her wheelchair. On 10/2/23 at 1:20 PM, V7, Certified Nursing Assistant (CNA), and V8, CNA, transferred R82 from her wheelchair to her bed. V7 and V8, CNAs, removed R82's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-04 · 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 implement R13's Care Plan interventions to reduce pressure on her stage 3 pressure ulcer for 1 of 4 residents (R13) reviewed for Pressure ulcers in the sample of 26. The findings include: R13's current Physicians Orders on 10/03/23 shows low air loss mattress ordered 08/29/23. R13's Care Plan on 10/03/23 shows, Actual alteration in skin integrity: Pressure Ulcer to sacrum. Intervention-Low Air loss Mattress initiated 08/24/23. On 10/03/23 at 9:49AM, R13 was in bed laying on her back. R13 was not on a low loss air mattress. On 10/03/23 at 10:15AM, V10, Wound Care Nurse, said, (R13) was admitted with a Stage three pressure ulcer. The low air loss mattress shoots air into the mattress alternatively so pressure is not on the wound continuously. (R13) just had a room change, and the staff may have left her mattress behind in her old room. The facility's Prevention and Treatment of Pressure Injury and Other Skin Alterations policy, dated 03/02/21, shows, Implement preventative measures and appropriate 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.
“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
$8,281 in federal fines across 1 penalty.
- $8,281 — penalty dated 2025-07-10
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 THE ALDEN NETWORK — 27 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 | 5 of 5 | 2.9 | +2.1 vs chain |
| Health inspection | 4 of 5 | 3.0 | +1.0 vs chain |
| Staffing | 2 of 5 | 2.1 | -0.1 vs chain |
| Quality measures | 5 of 5 | 3.6 | +1.4 vs chain |
The other 26 homes this chain runs (chain average 2.9★, 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 |
|---|---|---|---|---|
| THE ALDEN GROUP, LTD. | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 12/03/1987 |
| AUDRA ELISCO GRANTOR TR DATED 11/02/2004 | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 03/01/2018 |
| LAUREN MAGNUSSON GRANTOR TR DATED 11/02/2004 | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/28/2018 |
| RANDI SCHULLO GRANTOR TR DATED 11/02/2004 | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/28/2018 |
| ELISCO, ARIN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/01/2013 |
| ELISCO, CHARLES | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/01/2013 |
| MAGNUSSON, GARRETT | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/01/2013 |
| MAGNUSSON, PAIGE | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/01/2013 |
| SCHULLO, JOSEPH | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/01/2013 |
| SCHULLO, NICOLE | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/01/2013 |
| SCHULLO, RANDI | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | NO PERCENTAGE PROVIDED | since 02/16/2010 |
| MIDCAP FUNDING IV TRUST | Organization | 5% OR GREATER SECURITY INTEREST | — | since 07/01/2010 |
| CARROLL, ELIZABETH | Individual | W-2 MANAGING EMPLOYEE | — | since 11/12/2017 |
| CARL, JOAN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 12/03/1987 |
| SCHLOSSBERG, FLOYD | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 12/03/1987 |
| ALDEN MANAGEMENT SERVICES, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/03/1987 |
| DAVIS, ESTHER | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/15/2010 |
| MOLITOR, ROBERT | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 06/16/2008 |
CMS files one row per role, so the 21 rows in the source record cover these 18 parties — each is shown once here with every role it holds. Nothing is omitted.
6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $5.2M paid to related parties — landlords or management companies under common ownership — equal to about 29% 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 145403. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-04, 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.