Victorian Village Hlth & Well
12525 W Renaissance Circle, Homer Glen, IL 60491 · Non profit - Corporation · 50 certified beds · (708) 590-5050 Medicare only — no Medicaid
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (32% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has 1 actual-harm citation
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
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) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 15.6% | 13.4% | 15.4% | typical |
| Long-stay residents who lose too much weight | 5.9% | 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 | 1.4% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 54.2% | 6.5% | check this* — see note marked star 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 | 0.0% | 3.1% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents on antianxiety or hypnotic medication | 9.6% | 18.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.5% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 28.2% | 20.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.4% | 21.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.2% | 2.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 94.3% | 63.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 28.4% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 11.5% | 13.9% | 12.0% | typical |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ 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.
63.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 714 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 29.3% 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 427 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 0.77 therapist hours per resident per day in 2026Q1 — more than 94% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 27% 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 | 63.2%CMS range 60.1–66.7 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.2%CMS range 8.0–12.1 | 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 | 29.3% | 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 | 23.6% | 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 | 27.4% | 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 | 54.5% | 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 | 88.5% | 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 | 99.2% | 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 | 0.5% | 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 | 1.4% | 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 | 4.8%CMS range 3.5–7.0 | 7.1% | Oct 2023–Sep 2024 | better than U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.90 | 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 50 beds and averages 52.2 residents a day — about 104% occupied, or roughly -2 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 5.25 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 2.01 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.11 is at or above 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 4.68 hrs/resident/day on weekends vs 5.48 on weekdays — 15% thinner on weekends. RN hours go from 2.18 to 1.59 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 32% is below the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
22 citations, most serious first. The 11 most serious are shown; the remaining 11 are one tap away and print in full.
- Actual harm · Gcited before2026-03-26 · 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 follow the transfer method recommended by physical therapy and indicated in the resident's plan of care. This failure resulted in R1 sustaining a 12cm (centimeter) left lower leg laceration, transfer to the hospital, and laceration repair with 21 sutures.This applies to 1 resident (R1) reviewed for safe transfers in a sample of 4.The findings include:On 3/24/2026 at 1:24 PM, R1 was in bed with a gauze wrap on her left leg.On 3/24/26 at 4:07 PM, V5 (CNA/Certified Nurse Assistant) said on 3/4/26 V12 (CNA) asked her to assist with transferring R1. V5 said prior to the transfer, R1's wheelchair was next to her bed, facing the head of the bed, with R1's left leg next to the bed. V5 said she was standing behind R1's wheelchair, and did not touch R1 during the transfer. V5 said V12 told R1 to hold onto the bed rail with her left hand while V12 put her arms under R1's armpits while she stood up. V5 said V12 did not use a gait belt or sit to stand…
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 before2025-07-03 · tag F0808 — failed to follow doctor-ordered diets — patternEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
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 observations, interviews and record review, the facility failed to follow the planned menu plan for residents on diabetic diets. This applies to 4 of 4 residents (R10, R198, R202, R248) reviewed for dining in the sample of 13. The findings include: Daily menu spreadsheet for Monday June 30, 2025 lunch meal showed that dessert choice for all diets except for CCHO (Carbohydrate Controlled diet) was #8 scoop or 1/2 cup Cherry Cobbler. The dessert choice for the same meal for CCHO diets for diabetics included #8 scoop of spiced peaches. On June 30, 2025 at 12:30 PM, the lunch meal service was observed in the facility 2nd floor dining room with V8 CNA (Certified Nursing Assistant) and V9 (CNA) serving the meals from the server. V9 was noted slicing Cherry Cobbler in the server and passing it out to the residents seated in the dining room for dessert. 1.R10's face sheet had multiple diagnoses including Type 2 diabetes mellitus without complications, gastro-esophageal reflux disease without esophagitis,…
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 before2025-07-03 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Face sheet showed R21 is 73 years-old who has multiple medical diagnoses including aftercare following joint replacement surgery and infection and inflammatory reaction due to internal right knee prosthesis, subsequent encounter. Care plan dated June 9, 2025, shows R21 is receiving intravenous (IV) antibiotic therapy for 35 days related to prosthetic joint infection after a total knee arthroplasty (TKA). R21 was in his room on June 30, 2025, from 12:14PM until 12:40PM receiving care from V13 (Nurse). R21's room was noted with a sign showing, Enhanced Barrier Precautions and a set-up was noted outside R21's room door. During this time, V12 provided care to R21 (flushing an IV line, applying compression socks and changing dressing to the wound) without wearing an isolation gown. 3. R2 is 76 years-old who has multiple medical diagnoses including displace comminuted fracture of shaft of right femur, subsequent encounter for closed fracture with routine healing. On July 1, 2025, at 11:12 AM, V16 (Certified Nursing…
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 before2025-07-03 · 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 provide supervision during meals. This applies to 1 of 1 resident (R201) reviewed for eating supervision in the sample of 13 The findings include: R201's face sheet showed diagnoses including heart failure, asthma, chronic kidney disease, stage 2 (mild), diaphragmatic hernia without obstruction or gangrene, encounter for screening for respiratory tuberculosis, complete rotator cuff tear or rupture of right shoulder, not specified as traumatic. R201's MDS (minimum data set) dated June 20, 2025 showed that R201 needs substantial maximal assistance with eating. R201's POS (Physician Order Summary) June 13, 2025, showed diet order of CCHO [Carbohydrate Controlled diet] Heart Healthy diet, Regular texture, Thin Liquids consistency. Fluid Restriction and Maximum Supervision at meals. On July 01, 2025, at 09:09 AM, R201 was lying in bed with the head of bed raised at about 30-45-degree angle and eating breakfast from an over the bed table. R201's right arm was in a sling. R201 continued to cough in between mouthfuls…
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 before2025-06-05 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and procedure regarding privacy and confidentiality of health information. This applies to 2 of the 3 residents (R2, R3) reviewed for privacy/confidentiality in the sample of 5. The findings include: 1. The electronic medical record (EMR) shows R2 is 77 years-old who was admitted to the facility for a short-term rehab and was discharge from the facility on May 23, 2025. R1 was discharge with multiple medications including the Fluticasone furoate-vilanterol (Breo Ellipta) inhaler. However, on May 22, 2025 (the day prior to R2's discharge), R2's (inhaler) was sent with R1 when R1 was discharge that day. On June 2, 2025, at 8:58 AM, V15 (R1's Daughter) stated that she picked up R1 from the facility and brought him home with her. V15 found R2's Breo Ellipta inhaler when she started sorting through R1's medications that was provided by the facility. V15 called the facility to inform them about it. 2. The EMR shows R3 is 77 years-old who…
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 · D2025-06-05 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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 that all prescribed medication was provided to the resident upon discharge. This applies to 1 of 3 residents (R1) reviewed for discharge process in the sample of 5. The findings include: The electronic medical record showed that R1 is 93 years-old who was admitted to the facility for a short-term rehab, and was discharged from the facility on May 22, 2025, to his daughter's (V15's) home. R1's discharge order summary report showed multiple prescribed medications, including Metoprolol Succinate ER 12.5 milligrams (mg) twice a day. On June 2, 2025, at 8:58 AM, V15 (R1's Daughter) said she sorted through R1's medications when they got home, and observed that the prescribed medication, Metoprolol, was missing. However, V15 found a Breo Ellipta medication that belongs to R2, that was mixed among R1's discharge medications. On June 3, 2024, at 12:53 PM, V9 (Nurse) stated that part of their discharge process is to ensure that prescribed medications were reviewed, and dispensed medications were provided to the 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 · Fcited before2024-09-13 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain the kitchen facility in a manner to prevent foodborne illness. This applies to all 46 residents in the facility receiving dietary services. Findings include: On 9/11/24 at 3:42 PM V2 DON (Director of Nursing) confirmed on 9/10/24 all 46 residents of the facility received dietary services. On 9/10/24 at 10:08 AM, the facility main kitchen was toured with V9 Director of Dining Services. Dust was covering the vents over the stove. Open pots of food were cooking on the stove. Large Refrigerator- Zipped bag of 3 hot dogs dated 8/24/24. Ham loosely wrapped with plastic wrap open and exposed dated 8/29/24. Raw ground beef 10lb chub open end covered by plastic wrap meat gray. No opened on or use by date. Shredded Mozzarella cheese 5lb (pound) dated 8/26 bag open to air no use by date. Grated parmesan cheese 5lb opened dated 8/24/24. Yellow sliced cheese no labels no open on or use by dated. Corner of cheese hard. Grated parmesan 5lb bag…
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 · F2024-09-13 · tag F0887 — widespreadEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to offer COVID-19 vaccines to the facility's staff members and failed to provide education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine. This has the potential to affect all residents at the facility. Findings include: On 09/11/24 at 01:06 PM, V2 DON (Director of Nursing) said that he did not have any documentation to provide that the facility is offering the staff the COVID-19 vaccine or offering education about it. V2 said that the facility doesn't offer it anymore because it is too expensive. On 09/12/24 at 02:54 PM, V2 said that the facility has not offered any COVID-19 vaccine education to the staff in the last year. On 09/12/24 at 12:00 PM, V1 (Administrator) said that she has been at the facility since November 2023 and the facility has not offered COVID-19 vaccines to the staff or has had a COVID clinic since she has been here. V1 said that the facility should be offering the COVID-19 vaccine to staff. On 09/12/24 at 10:39 AM, V5 (Nurse) said that the facility has…
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 · D2024-09-13 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
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 guidelines for blood glucose monitoring. This applies to one resident (R35) reviewed for quality of care in a sample of 19. Findings include: R35's Face sheet shows a diagnosis of type 2 Diabetes Mellitus. R35's POS (Physician Order Sheet) shows an order dated 8/27/24 to check blood glucose twice a day. R35's Weights and Vitals Summary shows his blood glucose result on 9/10/24 at 9:34 AM was 72, and his blood glucose result on 9/12/24 at 8:00 AM was 88. On 9/11/24 at 8:11 AM, V18 (RN/Registered Nurse) was observed checking the blood glucose of R35. V18 first cleaned R35's finger with an alcohol wipe, then waved his gloved hand at the finger to dry the alcohol. V18 then poked R35's finger with lancet, squeezed out a drop of blood, wiped it with alcohol wipe, squeezed out a second drop of blood, and then placed that drop on testing strip to obtain blood glucose. The alcohol had not had enough time to dry from resident's finger after V18 wiped the first drop of blood off and placed the second…
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 · D2024-09-13 · 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, & record review, the facility failed to provide ADL care (activities of daily living) to dependent residents. This applies to 3 of 4 residents (R24, R27, & R30) reviewed for ADL care in a sample of 19. Findings include: 1. On 09/10/24 at 11:28 AM, R24 was observed in the dining room during activities, and she was observed scratching her head. At 12:26 PM, R24 was observed again but while she was being toileted and receiving incontinence care and R24 was still scratching her head and white flakes were observed on her shirt. At 01:09 PM, R24 was observed scratching her head and her nails were observed jagged with brown substance under the nails. R24's hair was observed dry with no oil present. R24 said that her head itches. R24's electronic health records showed that R24 is an [AGE] year old female admitted to the facility on [DATE] with diagnoses including encounter for palliative care, major depressive disorder, anxiety disorder & hypertension. R24's 8/19/24 MDS (Minimum Data…
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 before2024-09-13 · 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
Based on observation, interview, and record review, the facility failed to maintain indwelling urinary catheter according to best practice to prevent complications. This applies to 1 resident (R151) reviewed for urinary catheter in a sample of 19. The findings include: R151's Face sheet shows a diagnosis of chronic kidney disease. R151's MDS (Minimum Data Set) dated 8/21/24 shows her cognition is intact. R151's Care Plan revised on 9/10/24 shows the indwelling urinary catheter is to be reinserted due to urinary retention. Interventions include position the catheter bag and tubing below the level of the bladder and away from entrance room door. On 9/10/24 at 12:16 PM, R151 said my bladder is not working again, they are going to put a catheter in again. On 9/11/24 at 2:11 PM, R151 said they put my catheter back in again late yesterday afternoon. Surveyor then noticed while R151 was lying in bed, the urinary catheter drainage bag was not hooked to the bed frame or seen on either side of R151's bed. On 9/11/24 at 2:16 PM, surveyor noted that R151 was lying in bed and was wearing 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.
Show the remaining 11 citations
- Potential for harm · D2024-09-13 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to follow physician medication orders. This applies to one resident (R146) reviewed for quality of care in a sample of 19. Findings include: On 9/10/24 at 11:47 AM, R146 said her pain was getting up to an 8 (on a scale of 0-10) and she was just about to call the nurse to ask for a hydrocodone/acetaminophen pain pill. R146 said it had been about 4 hours since she last took pain medication and every 4 hours the pain starts to creep up again. R146's Face sheet shows diagnoses of history of falling and contusion of left lower leg. R146's POS (Physician Order Sheet) shows two orders for hydrocodone-acetaminophen PRN (as needed) pain medication. The first order shows hydrocodone-acetaminophen oral tablet 5-325mg (milligram) give 1 tablet by mouth every 4 hours as needed for moderate to severe pain *DO NOT EXCEED 3 GM (gram)/DAY ACETAMINOPHEN FROM ALL SOURCES*. The second order shows hydrocodone-acetaminophen oral tablet 5-325mg give 2 tablets by mouth every 4 hours as needed for moderate to severe pain *DO NOT EXCEED…
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 before2024-09-13 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, & record review, the facility failed to provide proper hand hygiene during incontinence care & while providing a physical exam. This applies to 3 of 4 residents (R24, R96, & R16) reviewed for bowel and bladder incontinence, and 1 of 4 residents (R30) reviewed for ADL care (Activities of Daily Living) in a sample of 19. The findings include: 1. On 09/10/24 at 12:48 PM, V3 CNA (Certified Nurse's Assistant) was observed toileting and providing incontinence care for R24. R24 was observed standing over the toilet and V3 was observed with gloved hands removing R24's soiled brief and then setting R24 on the toilet. V3 then was observed getting a tissue and cleaned R24's nose. V3 then removed her gloves and put on clean gloves but did not clean her hands. V3 then moved R24's (reclining high back) chair in her room, then returned to the bathroom, and removed her gloves and put on new gloves but did not clean her hands. V3 then grabbed a box of tissue and wiped R24's perineal area then…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-08-31 · 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 to store pots and pans in a sanitary manner and failed to discard dented cans. This applies to all 49 residents that reside in the facility. The findings include: Facility Resident Census and Conditions of Residents form (CMS Form 672) dated August 28, 2023, showed that the facility census was 49. Facility gave verbal confirmation that 48 residents received oral diets and one resident was on dual (oral and tube) feedings. On August 28,2023 at 9:41 AM, during the initial tour of kitchen, the dish room had multiple cleaned pots and pans inverted on trays that were placed on a free-standing rack. These trays were noted to have marked miscellaneous debris, dust and unknown dried stains or spills. This was brought to the attention of V15 (Director of Dining Services) who acknowledged the findings and stated that she will ensure that the holding trays be cleaned and the pots and pans rewashed. In the dry storage cabinet, there were two cans of Country Style Sausage Gravy (6 lbs/pounds and 8 oz/ounce each can) and one…
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 before2023-08-31 · tag F0808 — failed to follow doctor-ordered diets — patternEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
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 diet as ordered by the Physician. This applies to 5 of 5 residents (R1, R2, R11, R27, R30) reviewed for diet orders in the sample of 13. The findings include: 1. On August 28, 2023 at 12:49 PM, during lunch meal service in the dining room, R30 received small portions (per request) of meat loaf, mashed potatoes and vegetables. Facility diet order listing showed magic cup (fortified ice cream) twice a day and R30 did not receive the same. On August 29, 2023 at 12:28 PM, during the lunch meal service, R30 received small portion of braised turkey, green beans and noodles. R30 did not again receive magic cup. R30 stated that she receives ice cream only when she asks for it and that she likes the same. R30 added that nursing gives her nutritional supplement (Ensure) routinely but she doesn't care for it. On August 29, 2023 at 12:36 PM, V16 (CNA/Certified Nursing Assistant) stated that the meal service is completed. V16 added They got everything they should get. V16 added that there is no magic cup available…
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 · E2023-08-31 · tag F0925 — failed to control pests — patternMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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 and interview; the facility failed to maintain an effective pest control program. This applies to 5 of 5 (R9, R14, R15, R20, R31) residents reviewed for environment in a sample of 13. The findings include: 1. R14's admission record, showed R14 was admitted to the facility on [DATE]. R14 had multiple diagnoses including disorder of the muscle, malignant neoplasm of the prostrate, malignant melanoma of the skin, chronic pulmonary embolism, history of falling, and major depressive disorder. R14's MDS (Minimum Data Set) dated July 26, 2023, showed R14 was cognitively intact, and required limited assistance from staff with ADLs (Activities of Daily Living), including bed mobility, transfer, toilet use and personal hygiene. On August 28, 2023, at 11:20 AM, R14 stated he had too many flies in his room, while he spoke there were three flies observed on his pillow next to his head and two observed on his bedside table. On August 29, 2023, at 10:12 AM, R14 stated he still had flies in his room he said…
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 · D2023-08-31 · 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
Based on observation and interview the facility failed to ensure call lights were within reach of residents and operational. This applies to 3 of 3 residents (R17, R247, R250) reviewed for call lights in the sample of 13. Findings include: On August 28, 2023 at 10:35 AM, R250 stated she waited for 45 minutes for someone to answer her call light yesterday. R250 was asked to hit the call light to see if it worked. It did not work. The light did not illuminate inside the room on the call light panel, or illuminate outside of the room, or beep. On August 28, 2023 at 11:17 AM, R17 was sitting in her room in a wheelchair on the side of her bed. R17's call light was behind her and about 4 feet away, tied to the bed rail and not within R17's reach. On August 28, 2023 at 11:48 AM, R247 was sitting in her wheelchair and seems very lethargic. R247's eyes were mostly closed while she was talking. R247 stated she was very weak. R247's call light was in front of her about 4-5 feet away and not within her reach. The call light was wrapped around the bed railing. V6 (RN) was informed that R247 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 · Dcited before2023-08-31 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview the facility failed to provide privacy during a blood draw. This applies to 1 of 1 resident (R248) observed for blood draws in the sample of 13. Findings include: On August 28, 2023 at 11:23 AM V20 (Phlebotomist) was drawing R248's blood from his right arm while R248 was sitting at a table in the common area dining room on the second floor. R29 was also sitting in the same dining room at the same time. V20 finished drawing R248's blood and placed the vials of blood on the dining room table on top of a magazine in front of R248. The vials of blood rolled off the magazine and onto the table. V20 stated she was told by the company she works for that she could draw blood in the dining room if no one else was around. V6 (Registered Nurse) stated V20 should not be drawing blood in the dining room and then went over to tell V20 about it. V30 (Assistant Director of Nursing, ADON) then came over and introduced herself as the ADON to V20 (Phlebotomist). V30 told V20 that blood draws should not be done in the dining room and should be done in resident's room.…
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 · D2023-08-31 · 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
Based on observation, interview and record review the facility failed to assess and provide adaptive device/equipment to a resident, to prevent further reduction in mobility and ROM (range of motion). This applies to 1 of 1 resident (R12) reviewed for mobility and range of motion in the sample of 13. The findings include: R12 had multiple diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, fracture of unspecified part of the left clavicle and wedge compression fracture of unspecified thoracic vertebra, based on the face sheet. R12's admission MDS (minimum data set) dated August 14, 2023 showed that the resident was cognitively intact and required extensive assistance with her ADLs (activities of daily living). The same MDS showed that R12 had functional limitation in range of motion on one side of her lower extremity. On August 28, 2023 at 10:46 AM, R12 was in bed, alert, oriented and verbally responsive. R12 had weakness on her left arm and hand. R12 was not able to move her left hand without the help of her 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 · Dcited before2023-08-31 · 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
Based on observation, interview and record review the facility failed to ensure that a resident's urinary catheter tubing was kept off the floor to prevent potential urinary tract infection and trauma to the urinary tract. This applies to 1 of 2 residents (R5) reviewed for indwelling urinary catheter in the sample of 13. The findings include: R5 had multiple diagnoses which included UTI (urinary tract infection), retention of urine and stage 3 chronic kidney disease, based on the face sheet. R5's admission MDS (minimum data set) dated August 1, 2023 showed that the resident was moderately impaired with cognition and required extensive assistance from the staff with most of her ADLs (activities of daily living) including toilet use. The same MDS showed that R5 had an indwelling urinary catheter in place. On August 28, 2023 at 11:38 AM, R5 was sitting in her wheelchair inside her room, watching television. R5 was alert and verbally responsive. R5's urinary catheter tubing was resting directly on the floor. According to R5 she had history of UTI. On August 28, 2023 at 9:30 AM, R5 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 · D2023-08-31 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide oxygen therapy as ordered by the Physician. This applies to 2 of 2 residents (R10, R11) reviewed for oxygen in the sample of 13. The findings include: 1. R10's diagnoses on face sheet included diagnoses of chronic obstructive pulmonary disease, acute on chronic diastolic (congestive) heart failure, unspecified, encounter for palliative care, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, obstructive sleep apnea (adult) (pediatric), history of falling. R30's significant change MDS dated [DATE] showed that R10 was moderately impaired in cognition and required extensive assistance from the staff with ADL (activities of daily living) care except for eating. R10's POS (Physician Order Sheet) included Oxygen at 2L (liters) per nasal cannula continuously (order date June 15, 2023). On August 28, 2023 at 10:56 AM, R10 was seated in activities with portable…
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 before2023-08-31 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow their infection control policy and don personal protective equipment (PPE) required for transmission based precautions, and also failed to perform hand hygiene upon entering and exiting a room requiring transmission based precautions. This applies to 3 of 3 residents (R19, R249, R250) reviewed for infection control in the sample of 13. Findings include: R249's face sheet documents R249 was admitted to the facility on [DATE] with diagnoses including a right knee wound infection and Methicillin Resistant Staphylococcus Aureus (MRSA) infection. On August 28, 2023 at 10:53 AM V4 (Maintenance) was going from room to room checking to see if call lights are working. V4 started in R19's room turned on the call light in R19's room, came out to the entry to see if the call light was illuminated, and then went back in to turn the call light off. V4 then went into R249's contact isolation room without donning any PPE and did not sanitize 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.
“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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| REST HAVEN ILLIANA CHRISTIAN CONVALESCENT HOME | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 01/26/2015 |
| BREEMS, TIM | Individual | CORPORATE DIRECTOR | — | since 04/01/2024 |
| DEGRAFF, DAVE | Individual | CORPORATE DIRECTOR | — | since 04/01/2024 |
| FEENSTRA, THEODORE | Individual | CORPORATE DIRECTOR | — | since 04/02/2022 |
| KATS, STEVEN | Individual | CORPORATE DIRECTOR | — | since 04/01/2026 |
| KOLDENHOVEN, ARNOLD | Individual | CORPORATE DIRECTOR | — | since 04/01/2024 |
| LEO, GARY | Individual | CORPORATE DIRECTOR | — | since 04/01/2024 |
| PETROELJE, ROB | Individual | CORPORATE DIRECTOR | — | since 04/01/2024 |
| VAN ESSEN, DARREN | Individual | CORPORATE DIRECTOR | — | since 04/02/2022 |
| VAN SOLKEMA, KEVIN | Individual | CORPORATE DIRECTOR | — | since 04/01/2026 |
| VOSS, DAVID | Individual | CORPORATE DIRECTOR | — | since 04/02/2022 |
| WOO, ERIC | Individual | CORPORATE DIRECTOR | — | since 04/01/2024 |
| YONKER, KYLE | Individual | CORPORATE DIRECTOR | — | since 04/02/2022 |
| OTTE, LARRY | Individual | CORPORATE OFFICER | — | since 10/01/2025 |
| KRIEPS, JAMIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/07/2025 |
| MULKI, M GHAITH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2024 |
| ZANDSTRA, JOHANNA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2024 |
CMS files one row per role, so the 20 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.1M paid to related parties — landlords or management companies under common ownership — equal to about 10% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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
CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Illinois Medicaid page for homes that do.
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 146178. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-03, 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.