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Aliya Of Homewood

940 Maple Avenue, Homewood, IL 60430 · For profit - Corporation · 132 certified beds · (708) 799-0244 Medicare & Medicaid certified

Call the home — (708) 799-0244 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0602) — cited Aug 20248 actual-harm citations$123,708 in federal fines2 Medicare payment denials
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0602), cited Aug 2024
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 8 actual-harm citations
  • 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 $123,708 in federal fines (most recent 2026-02-20)
  • its payroll-based staffing rating is low (1/5)

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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
17960 Halsted St · (708) 922-0911 · Call to confirm hours
Pharmacy
17550 Halsted St · (708) 755-1320 · Call to confirm hours
Grocery
17705 Halsted St · (708) 957-1810 · Call to confirm hours
Park
1100 Ridge Rd · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 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 2 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.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased2.7%13.4%15.4%better
Long-stay residents who lose too much weight12.1%6.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.9%0.9%better
Long-stay residents with a urinary tract infection0.0%1.5%2.0%better
Long-stay residents with depressive symptoms99.6%54.2%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.7%3.1%3.3%better
Long-stay residents whose ability to walk worsened0.0%14.3%16.1%check this — see note marked star below the table
Long-stay residents on antianxiety or hypnotic medication12.4%18.3%18.9%better
Long-stay residents given the seasonal flu vaccine86.6%91.8%95.3%typical
Long-stay residents with pressure ulcers6.6%4.8%4.7%worse
Long-stay residents with worsening bladder/bowel control27.1%20.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table13.3%21.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.9%2.2%1.4%better
Short-stay residents given the seasonal flu vaccine67.3%63.1%79.4%worse
Short-stay residents rehospitalized after admission37.3%26.1%22.6%worse
Short-stay residents with an outpatient ER visit14.7%13.9%12.0%worse

* 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.

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.

54.9% 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 256 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

54.9%U.S. median 51.5%
Got home and stayed home
11.4%U.S. median 10.7%
Went back to hospital
69.7%U.S. median 56.6%
Met the expected recovery
0.48U.S. median 0.31
Therapy hours / resident / day
0.23hours / resident / day
Physical therapy
0.19hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 69.7% 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 122 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 0.48 therapist hours per resident per day in 2026Q1 — more than 79% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 39% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF54.9%CMS range 48.5–60.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.4%CMS range 8.8–15.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge69.7%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge66.4%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge49.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.5%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting87.3%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge94.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.5%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization9.6%CMS range 6.6–12.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.941.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.89
RN hours/ resident / day
0.94
LPN hours/ resident / day
1.82
Aide hours/ resident / day
3.65
Total nurse hours/ resident / day
0.95
RN hoursweekends
40.2%
Total nursing turnover
55.6%
RN turnover

How full it usually is: this home is certified for 132 beds and averages 115.0 residents a day — about 87% occupied, or roughly 17 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.65 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.89 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.82 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.53 hrs/resident/day on weekends vs 3.70 on weekdays — 5% thinner on weekends. RN hours go from 0.87 to 0.95 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 40% is about the same as 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

10
deficiencies at the latest standard inspection (2026-02-20)
2
at the previous standard inspection (2024-11-15)

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.

ABCDEFGHIJKL

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

29 citations, most serious first. The 18 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 — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that required fall prevention interventions were on the care plan, failed to implement fall prevention interventions, failed to ensure that risk assessments were accurate, failed to ensure that staff were aware of resident falls/injury, failed to ensure that staff were aware of resident transfer requirements, and/or failed to provide supervision to four of four residents (R2, R3, R4, R5) reviewed for falls. These failures resulted in the following serious injuries; R5's (3/16/26) fall with sustained head laceration - requiring staple repair and R4's (2/6/26) fall with sustained eyelid laceration. The facility also failed to ensure that physical assessments (post fall) were accurate.Findings include:The (1/23/26-3/23/26) Facility Falls Incident log affirms that 42 falls occurred - within 2 months.The Falls Incident log affirms that R5 fell on 3/13/26 and 3/16/26. R5's diagnoses include anxiety, restlessness, agitation, hemiplegia and hemiparesis. R5's (3/19/26)…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2026-02-20 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to notify the physician and registered dietitian of a resident's poor appetite and decreased oral intake, which resulted in significant weight loss, and failed to implement timely interventions to prevent further decline. This affected one of three residents (R9) reviewed for nutritional status in a sample of 44 residents. This failure resulted in R9 experiencing a significant unplanned weight loss of 13.3% over a three-month period.Findings include: On 2/17/26 at 12:47 PM, R9 received lunch meal tray. R9's head of bed was at 45 degrees. At 1:10 PM, R9 was observed eating one piece of canned fruit. R9 was observed coughing while eating. By 1:25 PM, R9 had consumed two pieces of canned fruit and drank 100 ml (milliliters) juice. V20 CNA (certified nurse aide) removed R9's tray from room.On 2/18/26 at 1:12 PM, R9's lunch tray was set up and head of bed 45 degrees. By 1:36 PM, R9 had not eaten anything. By 2:15 PM, R9 ate one bite of cornbread. R9 was observed coughing while eating. V20 CNA removed R9's tray from…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2026-02-20 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure 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 ensure that residents who were at risk for malnutrition and dependent on enteral feedings received nutrition as ordered to maintain adequate nutritional status and prevent weight loss. The facility also failed to ensure staff demonstrated competency in the administration and management of enteral nutrition and care. This affected 2 of 3 residents (R82 and R89) reviewed for enteral nutrition in a sample of 44 residents. As a result, R82 experienced a significant weight loss of 14.1% between July 2025 and February 2026, and R89 experienced a weight loss of 4.4% within eight weeks of admission. Findings include: On 2/17/26, intermittent observations were made from 12:20 PM until 4:00 PM, R82 was observed self-propelling wheelchair in halls and attending activities; R82 was not connected to enteral feeding pump.On 2/18/26 at 3:36 PM, R82's enteral feeding container shows R82 received 600ml since it was started on 2/17/26 at 10:09 PM. Continuous observations were made on R82's nursing unit from 11:55 AM until 4:00…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2025-07-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record review, the facility failed to prevent an injury of unknown origin which occurred for one resident. This affected one of three residents (R1) reviewed for injury of unknown origin. This failure resulted in R1 sustaining an undetermined injury of an acute left humeral neck with displaced transverse fracture.Findings Include:R1's referral package dated 8/17/22 documents: past medical history of falls, osteoporosis and closed hip fracture. R1 was admitted with the diagnosis of Age-Related Osteoporosis without current pathological fracture. Minimal data set section C (Brief interview for mental status) dated 6/3/25 document a score of four (4) which indicates severe cognitive impairment. Section GG (functional abilities) documents: R1 required substantial/maximal assistance with upper body dressing, the ability to dress and undress above the waist: including fasteners, if applicable. Event report dated 6/29/25 documents: At approximately 4:00pm on 6/29/25, the assigned V6 (CNA) reported to V8 (nurse) that following taking R1's blood pressure with the vital…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2025-05-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor a resident (R2) sitting on the side of the bed when preparing R2 for a transfer when R2 reached for an item on the ground causing R2 to fall off the bed for one out of three residents reviewed for falls in a total sample of eight. The failure resulted in R2 needing to be hospitalized after suffering a laceration to the head and a subarachnoid hemorrhage. Findings Include: R2 is an [AGE] year old with the following diagnosis: traumatic subdural hemorrhage, aphasia, hemiplegia affecting the left side, glaucoma, and cognitive communication deficit. Nursing note dated 4/5/25 documents the CNA reported to the nurse that as the CNA was turning to grab R2's wheelchair, R2 fell forward from a sitting position on the side of the bed. R2 struck R2's head on the nightstand before landing on the floor on the left side. The nurse assessed R2 and noted a small laceration to the left side of the forehead with moderate bleeding. A pressure dressing was applied…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2024-08-01 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY A. Based on interview and record review, the facility failed to follow physician orders by not obtaining a urinalysis and culture for one resident who was identified as being incontinent of urine with a new onset of lethargy. This affected one of three residents (R4) reviewed for physician orders. This failure resulted in R4 being sent to the hospital with a diagnosis of urinary tract infection and sepsis. B. Based on interview and record review, the facility conduct a comprehensive body assessment on a resident observed with his left leg/knee contorted under his wheelchair, facial grimacing and yelling out with movement. This affected one of three residents (R3) reviewed for quality of nursing and assessment. This failure resulted in R3 waiting twenty hours for an x-ray order which resulted in a diagnosis of a new acute transcervical left femoral neck fracture with marked impaction and varus angulation. Findings include: A. R4 was admitted to the facility on [DATE] with a diagnosis of hemiplegia, abnormalities…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-08-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement effective individualized fall interventions to include supervision/monitoring and reduce the risk of multiple falls. This affected two of three residents (R2, R8) reviewed for falls prevention interventions. This failure resulted in R2, who had a diagnosis of Dementia and Alzheimer's disease and identified as high fall risk sustaining a second unwitnessed fall from bed requiring hospitalization for an acute comminuted displaced fracture of the bilateral nasal bones and one centimeter lip laceration. In addition, the facility left R8 unsupervised on the floor for 13 minutes following an unwitnessed. Findings include: R2 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease, weakness, and dementia. Resident's brief interview for mental status score dated [DATE] documents a score of 3/15 which indicates severe cognitive impairment. R2's fall risk assessment dated [DATE] documents a score of 21 which…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-03-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to have effective fall interventions in place for a resident assessed to be at risk for falls and failed to provide two staff assist when providing assistance with Activities of Daily Living (ADL) per the resident's plan of care. This failure applied to one (R3) of three residents reviewed for falls and resulted in R3 sustaining a fall while being provided with care from one staff and resulted in R3 being transferred to the hospital and diagnosed with a subdural hematoma measuring 2mm. R3 subsequently returned to the facility with a neck collar and gastrostomy feeding tube (G-Tube). Findings include: R3 is an [AGE] year-old female who has resided at the facility since 2022, with past medical history including, but not limited to Chronic obstructive pulmonary disease, dementia, heart failure, hypertension, hypothyroidism, etc. Fall risk assessment dated [DATE] and 4/22/2023 score R3 as a 13, indicating that resident is at risk for falls. Facility minimum…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-26 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 policy procedures, failed to ensure that resident risk assessments were completed, and failed to ensure that a risk assessment was accurate for one of four residents (R4) reviewed for falls. Findings include:R4's (1/2/26) post fall risk assessment determined a score of 7 (at risk) however section G: Falls, Accidents, Fractures; was not answered (the responses were blank) therefore incomplete. History of falls and/or fracture in the past 6 months? include the current fall incident (was not selected). The assessment was conducted post fall therefore this response should have been selected. This selection adds 10 additional points to the score [Scoring a 10 or higher makes resident High Risk for falls]. On 3/25/26 at 12:51pm, surveyor inquired about concerns with R4's (1/2/26) post fall risk assessment. V2 (Director of Nursing) stated, Letter G is not checked, it's gonna throw the score off. Surveyor inquired what the score should have been if accurately assessed. V2 responded, It would be 17.The fall prevention 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-26 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    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 policy procedures and failed to ensure that required diagnoses/interventions were included in the baseline care plan for one of four residents (R2) reviewed for falls.Findings include:R2 was admitted to the facility on [DATE] with diagnoses including history of falling and fracture of right pubis. R2 fell at the facility on 2/17/26.R2's (2/14/26) Physician Order Sheets include non-weight bearing to right leg for right pelvic fracture. R2's (2/15/26) care plan states resident is high risk for falls related to reduced mobility and poor safety awareness [right pelvic fracture is excluded]. Interventions include bed in lowest position, keeping frequently used items within reach, placement of call light within reach and staff to assist as needed [non-weight bearing and transfer requirements are excluded].On 3/23/26 at 11:28am, surveyor inquired about R2's fall plan of care. V2 (Director of Nursing) reviewed R2's baseline care plan and responded,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-02-20 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews, this facility failed to follow its call light response policy and ensure the call light cord was within reach for 4 residents (R60, R91, R114, and R126) out of 4 residents reviewed for call light accessibility in a sample of 44. Findings include:On 2/17/26 at 10:05 AM, R60 was observed sitting in a wheelchair across from bed. R60's call light cord was observed on the floor under R60's bed, not within reach.On 2/17/26 at 12:20 PM, R126 was observed lying in bed. R126's call light cord was observed on floor under bed, not within reach.On 2/18/26 at 11:00 AM, R91 was observed sitting in a reclining chair next to the foot of her bed. R91's call light cord was observed on R91's nightstand at the head of the bed, not within reach.On 2/18/26 at 11:50 AM, R114 was observed lying in bed. R114's call light cord was observed dangling behind R114's nightstand, not within reach.On 2/17/26 at 10:06 AM, V24 (nurse) stated that the resident's call light cord should definitely be within the resident's reach.The facility's call light response…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-02-20 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received timely incontinence care, hygiene, and skin care services at least every two hours to maintain cleanliness, prevent skin breakdown, and promote comfort. This affected five of six residents (R126, R9, R89, R44, and R11) reviewed for activities of daily living (ADL) care, incontinence care, and hygiene/skin care in a sample of 44 residents. On 2/17/26 at 12:45 PM, V20 CNA (certified nurse aide) stated that R126 was last changed at 6:30 AM when V20 started her shift today. On 2/20/26 at 11:15 AM, V2 DON (director of nursing) stated that staff are expected to provide incontinence care to their assigned residents every two hours and as needed. R126: On 2/17/26 at 12:20 PM, R126 stated that R126 needs brief changed. R126 stated that he is able to activate the call light for assistance but does not know where his call light cord is. R126's call light cord observed under R126's bed. On 2/17/26 at 12:26 PM, V24 (nurse)…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-02-20 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications were labeled and stored in accordance with facility policy and accepted standards of practice. Specifically, opened and used medications located on the medication cart were not dated upon opening. This affected four of four residents (R 39, R140, R82, and R58) reviewed for medication storage. Finding Includes:On [DATE] at 3:59pm, during a medication cart audit with V14 (nurse), R39 was observed with an Latanoprost eye drops opened and not dated. V14 said, R39's eye drops are open, used and not dated. V14 said, R39's eye drops should have been dated upon opening. Dating the medication is to ensure its not administered past the expiration date.R39 was diagnosed with Glaucoma. R39's physician order sheet documents Xalatan Ophthalmic Solution. Instill one drop in both eyes in the evening for glaucoma. Pharmacy recommended expiration dates documents: Xalatan-expiration six (6) weeks.On [DATE] at 4:04pm, during a medication…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-20 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    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 obtain consent for psychotropic medications prior to administration for two of two residents (R3 and R113) reviewed for resident's rights in a total sample of 44 residents.Findings include:R3 was admitted to the facility on [DATE] with a diagnosis of schizophrenia, seizures, and traumatic subdural hemorrhage.R3's physician order sheet documents: Seroquel 50mg two tablets at bedtime order and start date 1/21/26, duloxetine 30mg one tablet daily with order date of 1/19/26 and start date of 1/20/26 and mirtazapine 30mg one tablet at bedtime with order date of 1/19/26 and start date of 1/20/26.R3's consent for psychotropic medication dated 1/21/26 documents under medications Seroquel, duloxetine and mirtazapine, under family it documents verbal consent received on 2/1/26 at 5:30PM by V38 (family member). Under facility representative V2 signature dated 2/4/26. The signing date of the assessment documents 2/19/26. V38 interview attempted but unsuccessful…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-20 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    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 Psychotropic Medication Program by not conducting psychotropic medication assessments as indicated, not conducting Abnormal involuntary movement scale assessments as indicated and failing to develop individualized nonpharmacological interventions for two of five residents (R104 and R113) reviewed for unnecessary medications in a total sample of 44.Findings include:R104 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease, psychosis, vascular disease and anxiety.R104' s psychiatrist note dated 2/10/26 documents; R104 currently treated with mirtazapine 15 mg at bedtime, sertraline 12.5 mg daily and Seroquel 25 mg twice a day.R104's care plan dated 3/10/24 revised 6/8/24 documents: R104 requires the use of psychotropic medication for diagnosis of psychosis and antidepressant medication for poor appetite. Interventions include administrator medication as ordered dated 3/10/24; antidepressant side effects:…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-20 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that wound care treatments and pressure ulcer prevention interventions, including repositioning and turning, were implemented as ordered. This affected one of eight residents (R11) reviewed for pressure ulcers in a sample of 44 residents R11's face sheet shows diagnosis of hemiplegia, hemiparesis following cerebral infraction affecting left non dominate side, type two diabetes. R11's wound assessment dated [DATE] shows coccyx wound, type; pressure, source; facility acquired, clinical stage;3, date identified 2/28/2023, care goal; decrease ulcer area, approach; off-loading, optimizing moist wound healing. On 2/19/26 at 9:51am during continuous observations from 9:51am to 12:00pm R11 was observed resting on her back in supine position at 45 degrees (position confirmed by V30-LPN). The facility staff did not turn and reposition R11 during this continuous observation. Staff were observed standing at R11's room doorway at 10:30am,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-20 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    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 licensed nurses demonstrated the competencies and skills necessary to safely manage and monitor residents receiving enteral nutrition via feeding pump, in accordance with professional standards of practice, placing residents at risk for complications related to improper administration and monitoring of enteral feedings. This affected three of three residents (R4, R82, R89) who were receiving enteral nutrition in a sample of 44 residents.Findings include:On 2/17/26 at 10:30 AM, R82 was observed in room. Intermittent observations were made from 12:30 PM until 4:00 PM, R82 was observed self-propelling wheelchair in halls and attending activities; R82 was not connected to enteral feeding pump.On 2/17/26 at 10:15 AM, R89 was observed lying in bed. R89's enteral feeding pump was turned off. Intermittent observations were made from 12:30 PM until 4:00 PM, R89 was in wheelchair at nurses' station not receiving enteral feeding.On 2/19/26 at 3:30 PM, V29 (activity director) stated that R82 is in wheelchair…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-20 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews, the facility failed to follow its infection prevention and control policy and don appropriate PPE (personal protective equipment) prior to entering resident rooms with enhanced barrier precautions and providing direct resident care. The facility also failed to place a resident with a gastrostomy tube in enhanced barrier precautions. These failures affected three residents (R78, R82, and R89) out of 6 residents reviewed for infection control in a sample of 44.Findings include:On 2/17/26 at 11:35 AM, V22 CNA was observed bringing clean linen into R78's room; V22 had gloves on. V22 did not don a gown prior to entering R78's room to provide direct resident care. There was signage noted on R78's door for EBP and a bin with PPE located next to R78's door. At 11:51 AM, V22 exited R78's room carrying soiled linens.On 2/17/26 at 12:20 PM, this surveyor observed an enteral feeding pump at R89's bedside. There was no signage for enhanced barrier precautions (EBP) noted on or near R89's door. There was no bin with PPE outside of R89'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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · D2024-11-15 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to ensure the antibiotic prescribed include duration, care plan, and documentation of long term used. This deficiency has the potential to affect 1 of 2 residents (R103) reviewed for antibiotic use in a sample of 23. Findings Include: On 11/12/2024 at 12:31PM, R103 on Enhanced Barrier Precaution (EBP). R103 said he takes medication for infection. On 11/14/2024 at 01:02PM, R103 said he knows he is on antibiotic medication for infection but does not know the name and has been taking it since he came to facility in September 2024. On 11/14/2024 at 10:35AM, V4 (Infection Control Nurse) said R103 is prescribed antibiotic, Metronidazole, should include a start and stop date along with indication for use. V4 said as part of Antibiotic Stewardship program, V4 review all antibiotic prescribed within a day or two of admission and communicate to the doctor if the duration is not indicated and document on resident medical records. V4 said the antibiotic prescribed for R103 on September admission should have a stop date. 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-15 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement ongoing monitoring of antibiotics. This deficiency affects one (R103) of three residents in the sample of 23 reviewed for Antibiotic Stewardship Program. Findings include: On 11/14/2024 at 10:36AM, V4 (Infection Preventionist) said that she reviews the antibiotic medications prescribed weekly and an infection assessment evaluation is done prior to the start of antibiotic use for the purpose of monitoring for the antibiotic stewardship program. V4 said that R103 is currently on Metronidazole 500mg every 12hours for bacterial infection with no stop date. V4 said she is unable to locate R103's infection assessment evaluation record upon start of antibiotic. On 11/14/24 at 1:58PM, V2 (Director of Nursing) said that her expectations for the antibiotic stewardship program should be an ongoing monitoring of antibiotics. R013 admitted on [DATE] with diagnosis listed in part but not limited to sepsis unspecified organism, periprosthetic…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-01 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately 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 their physician of an acute change in condition as noted in their change in condition policy. This failure affected one of three residents (R3) reviewed for change in condition. The failure contributed to a delay in treatment orders for R3 of over 24 hours. Findings Include: On 7/25/24 at 3:13PM, V10 (Nurse) said, V13 (CNA) updated her that R3 was yelling when V13 touched his left leg. R3 had a history of left knee pain. V10 said, R3 allowed her to move his left leg. R3 was in pain, and grimaced when she attempted to reposition R3 in the wheelchair. V10 said, she is not sure what happen after that because she ended her shift earlier than scheduled. V10 said, R3 was sent to the hospital the following day. V10 said, she thought R3 was having knee pain. On 7/25/24 at 3:30pm, V13 said, she was passing dinner trays. R3 was in his room sitting by the closet which was odd. R3 was normally in the hallway, self-propelling, using his feet and the handrail to go up and down the hallway. V13 said, she placed R3's dinner tray 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-01 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    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 internal refund process policy by not providing a refund of $19, 950.00 within 30 days from the death or discharge date . This affects one resident (R1) of three residents reviewed for misappropriation of resident's funds. Findings Include: R1 admitted in the facility on [DATE] under hospice private pay and expired in the facility on [DATE]. On [DATE] at 12:35PM V3 (Senior Business Manager) stated, private pay put one month and one month deposit, prior to admission or the day of admission. The rate is $21,000 down for private pay and for semiprivate room, this is for one month payment and one month deposit. V3 stated that they have 30 days to send the refund check to resident and family once the resident has been discharged or expired in the facility. On [DATE] at 1:15PM, V3 returned and informed surveyor that V3 called corporate and they were made aware that the person that handles the refund check in corporate is not available, 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-21 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to follow their policy to ensure housekeeping staff inspected the privacy curtains in resident rooms and removed visibly soiled privacy curtains. This failure has the potential to affect 5 (R2, R3, R4, R5, and R6) residents reviewed for a clean, comfortable, homelike environment. Findings include: On 03/19/24 at 12:40 PM, R2 was asked of her concern with housekeeping. R2 said, The housekeeper comes in everyday and cleans my room. Me and my daughter have told them about this curtain. See it has stains that look like stool on it. The staff said they could take it down and wash it, but they haven't done anything. We noticed the curtain was filthy when I came to this room. Surveyor observed the privacy curtain with multiple large brown and tan stains on both sides. On 3/19/24 at 1:00 PM, surveyor observed the privacy curtains in R5 and R6's room. The privacy curtains were visibly stained and dirty. V9 CNA (Certified Nurse Assistant) was in the room at this time assisting the residents with lunch. V9 was asked…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-12-14 · tag F0755 — failed to provide safe pharmacy services — widespread
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and record reviews, the facility failed to follow manufacturer's guidelines for dating a multidose vial when opened. This deficiency has the potential to affect all 109 residents currently residing in the facility. Findings include: Per resident census dated 12/11/23, there were 109 residents in the facility. On 12/11/23 at 11:35 AM during inspection of the three medication rooms in the facility, the following were observed: Rosewood East: three vials of opened of Tubersol Tuberculin Purified Protein Derivative (Mantoux) Multi dose vial 5TU/0.1ml (tuberculin units per 0.1 milliliter) Intradermal were opened but not dated. V10 (Registered Nurse, RN) was asked if there is a need to put a date on the vial when opened. V10 stated, I am not sure if we have to date it or not. Rosewood West: One multidose vial of Tubersol Tuberculin Purified Protein Derivative (Mantoux) was also opened but not dated. Per V11 (RN), It should have been dated when opened. Regency: One multidose vial of Tubersol Tuberculin Purified Protein Derivative (Mantoux) was opened but…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-12-14 · tag F0803 — failed to meet residents' dietary needs — widespread
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to follow their menu and failed to provide appropriate and approved menu changes and substitutions. This failure has the potential to affect 108 residents who are currently receiving meals and dietary services in the facility. Findings include: Per facility's Diet Type Report dated 12/12/23 shows that one resident on NPO (Nothing per Oral). Per facility census dated 12/11/23, shows 109 residents currently residing in the facility. Diet spreadsheet dated 12/11/23, shows dessert for lunch meal is fruit cobbler. Diet spreadsheet dated 12/12/23, shows lunch meal should include tossed salad and baked apples. On 12/11/23, observed gelatin with whipped cream being served for lunch meal. On 12/12/23, observed mixed fruit being served for lunch meal. On 12/12/23 at 11:54AM, observed fifteen residents to be eating in main dining room for lunch. Observed thirteen residents in main dining room to not be served. Lunch menu dated 12/12/23 posted in resident area shows dessert listed as 'delicious dessert'. On 12/12/23 at…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-12-14 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 follow their policies on food service sanitation and storage by not taking temperatures prior to the start of meal service; failed to ensure the freezer temperature is at 0 degrees or below; failed to place dirty dishes separate from clean dishes; and failed to confirm sanitizer bucket PPM was suitable for use. This failure has the potential to affect all 108 residents who are currently receiving meals and dietary services in the facility. Findings include: Per facility's Diet Type Report dated 12/12/23 shows that one resident on NPO (Nothing per Oral). Per facility census dated 12/11/23, shows 109 residents currently residing in the facility. On 12/11/23 at 9:40AM, observations in the kitchen were made with V12 (Dietary Director). Walk-in freezer was noted to be at 11 degrees Fahrenheit. V12 said this freezer has been a concern for a couple months and is not holding appropriate temperature. Administration is aware and they are saying we need to replace something within the freezer. However, nothing has been…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-12-14 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    A. Based on interviews and record reviews, the facility failed to follow its policy on water management program related to prevention of Legionella organism in the water system by not treating positive testing sites and not immediately obtaining treatment recommendations. This deficiency has the potential to affect the 109 residents currently residing in the facility. B. Based on observation, interview, and record review, the facility failed to ensure that staff practice appropriate hand hygiene as outlined in their medication administration policy and failed to ensure that staff appropriately dispose sharps in a sharp disposal container. This failure affected two (R39 and R79) of five residents reviewed for infection control. Findings include: A. Per resident census dated 12/11/23, there were 109 residents in the facility. Facility's Legionella test reports recorded the following: 08/18/23: Internet cafe sink - positive, 0.5 CFU/ml (colony forming unit per milliliter) Regency Shower room - positive, 5.0 CFU/ml Kitchen ice machine - positive, 0.5 CFU/ml Species found: Legionella…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-12-14 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that dependent residents are assisted with getting out of bed and failed to provide assistive device for a resident (R86) who was assessed as being at risk for complications due to musculoskeletal problems. This failure affected four (R28, R86, R89 and R98) of nine residents reviewed for activities of daily living (ADLs). Findings include: R86 is a [AGE] year-old female who has resided at the facility since 2022, with past medical history including but not limited to encounter for surgical aftercare following surgery on the digestive system, difficulty walking, unspecified osteoarthritis, disorder of muscle, etc. 12/11/23 11:20AM, R86 was observed in her room, awake, alert and oriented and stated that she is doing okay, she would like to get up more often, she is tired of staying in bed, the last time she got up was last week, she used to have a wheelchair, but it was taken away now she does not have any. She added that her…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-14 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were able to engage in the Activity Program upon request and failed to assess for recreation and activity needs upon admission. This failure affected two (R89 and R98) of 44 residents reviewed for activities. Findings include: During resident screening, R89 and R98 (roommates) were interviewed regarding care they were receiving in the facility. On 12/11/23 at 10:35AM, R89 and R98 were both observed alert and oriented lying in bed, dressed in medical gowns. R89 and R98 shared concerns of not being able to attend activities despite their desire to do so. R89 is [AGE] years old and was admitted to the facility 3/15/23 with diagnoses that included Multiple Sclerosis and hemiplegia of the left side. R98 is [AGE] year-old admitted to the facility 3/27/23 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction. During resident observation and interview, R89 pointed to the wall and said, the staff…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$123,708 in federal fines across 3 penalties. 2 Medicare payment denials on record.

  • $70,110 — penalty dated 2026-02-20
  • $10,358 — penalty dated 2025-07-18
  • $43,240 — penalty dated 2024-08-01
  • Medicare payment denial — starting 2026-03-21 for 7 days
  • Medicare payment denial — starting 2025-08-15 for 16 days

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 ALIYA HEALTHCARE — 14 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.0≈ chain avg
Health inspection 3 of 52.1+0.9 vs chain
Staffing 1 of 51.4-0.4 vs chain
Quality measures 4 of 53.8+0.2 vs chain
The other 13 homes this chain runs (chain average 2.0★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
ALIYA PM HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 02/01/2023
ALIYA OPERATIONS HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 02/01/2023
HAVEN CAPITAL LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 02/01/2023
ERLICH, MOSHEIndividualINDIRECT OWNERSHIP INTERESTsince 02/01/2023
WEINFELD, AVRUMIndividualINDIRECT OWNERSHIP INTERESTsince 02/01/2023
WEINFELD, DVORAHIndividualINDIRECT OWNERSHIP INTERESTsince 02/01/2023
ECAPITAL HEALTHCARE CORPOrganization5% OR GREATER MORTGAGE INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 07/14/2024
WEINFELD, EFRIAMIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2023
LINN, LEILANIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/11/2023
NAGUBADI, SANDHYAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2023
WELLTOWER INCOrganizationADP OF THE SNFsince 02/01/2023

CMS files one row per role, so the 18 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.

5 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.

$13.0M
Net patient revenuemost recent cost report
-0.4%
Operating marginrevenue minus expenses
$658K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 59%Medicare 10%Other / private 31%

This home reported $658K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$358per resident / day
operating cost
$10,871per month
≈ monthly operating cost
$356per day
avg. revenue, all payers

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

What families pay in IL

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.

Typical monthly cost in Illinois
$8,304/mo
Nursing home (semi-private)
$9,216/mo
Nursing home (private)
$6,219/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145684. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-20, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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