Bella Terra Lagrange
4735 Willow Springs Road, La Grange, IL 60525 · For profit - Limited Liability company · 120 certified beds · (708) 352-6900 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2024
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- 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
- its payroll-based staffing rating is low (2/5)
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 2 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 | 4 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 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 5.0% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.1% | 6.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 4.0% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 94.6% | 54.2% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.8% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 4.7% | 14.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 10.6% | 18.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 89.5% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.6% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 14.9% | 20.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.3% | 21.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 2.8% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 57.1% | 63.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 32.2% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 11.5% | 13.9% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.83 | 2.02 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.71 | 2.22 | 1.80 | worse |
‡ 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.
54.5% 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 211 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 61.4% 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 88 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 0.42 therapist hours per resident per day in 2026Q1 — more than 72% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 34% 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 | 54.5%CMS range 45.8–62.2 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 14.3%CMS range 10.9–16.9 | 10.7% | Oct 2022–Sep 2024 | worse than 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 | 61.4% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 63.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 58.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.3% | 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 | 87.8% | 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 | 95.3% | 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 | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.9% | 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 | 7.9%CMS range 5.3–11.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.01 | 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 120 beds and averages 100.3 residents a day — about 84% occupied, or roughly 20 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.54 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.03 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.84 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 3.39 hrs/resident/day on weekends vs 3.60 on weekdays — 6% thinner on weekends. RN hours go from 1.02 to 1.05 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 36% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
29 citations, most serious first. The 10 most serious are shown; the remaining 19 are one tap away and print in full.
- Potential for harm · F2025-03-28 · 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 staff the Covid-19 immunization vaccine and have written documentation of it. This applies to all 97 residents in the facility reviewed for immunizations in the sample of 24. The findings include: The CMS (The Centers for Medicare and Medicaid Services) form 671 titled Long-Term Care Facility Application for Medicare and Medicaid dated 3/25/25 shows the facility has a census of 97 residents. On 3/26/25 at 2:02 PM, V3 (LPN-Licensed Practical Nurse/Infection Preventionist) stated, I don't have the documentation that shows where I offered the vaccine to staff. Now, our corporate changed their policy. The Covid vaccines are not free anymore. The staff must use their own insurance, so we tell them that they can get the Covid-19 vaccines from clinics or pharmacies that accept their insurance. We don't offer it to them, but they can ask us to give it to them if they have insurance. V3's infection control binders did not have any documentation that staff were educated regarding the benefits and potential side effects of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-03-28 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide to a resident and/or their representative in writing for the reason of transfers to the hospital, and failed to notify the ombudsman of the transfers. This applies to 4 of 4 residents (R4, R46, R70, and R75) reviewed for discharge in a sample of 24. The findings include: 1. R4's Face Sheet showed R4 was admitted to the facility on [DATE]. R4 had multiple diagnoses which included moderate protein-calorie malnutrition, osteomyelitis of vertebra, Alzheimer's Disease, chronic kidney disease, and adult failure to thrive. R4's MDS (Minimum Data Set) dated 03/10/25 showed R4 was cognitively impaired. R4's Change in Condition with SBAR (Situation, Background, Assessment, Recommendation) Form dated 02/22/25 showed R4 had a change in condition with delayed response and an elevated heart rate. The same form showed R4 was transferred to the hospital via emergency medical transport on 02/22/25. The form showed written notice for reason of transfer was not…
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 · E2025-03-28 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct required care plan meetings and invite residents to participate in their care plan meetings. This applies to 4 of 4 residents (R20, R32, R69 and R79) reviewed for care planning in a sample of 24. Findings include: 1. R32's MDS (Minimum Data Set) dated 2/12/23 shows he is cognitively intact. On 03/25/25 at 11:45 AM, R32 stated he did not know what a care plan meeting was and had never been invited to one and feels the doctors make changes to his medications without discussing it with him. No documentation for care plan meetings were noted in R32's EMR. The facility was unable to provide any care plan meeting documentation for R32 for the past year. 2. R69's MDS dated [DATE] shows he is cognitively intact. On 03/25/25 at 10:40 AM, R69 stated he had been in the facility over two years and has never been invited to a care plan meeting. The only care plan documentation in the EMR able to be provided by the facility for R69 is dated 11/13/24. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-03-28 · tag F0694 — patternProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure a resident's IV (intravenous) antibiotic therapy bag was labeled. This applies to 1 of 1 resident (R81) reviewed for IV's in sample of 24. The findings include: On 3/25/25 at 10:18 AM, during initial tour, R81 was lying in bed. There was an IV pump toward the right side of R81's bed. There was an empty IV bag of Ceftriaxone without any label that included the date and time by the nurse. R81 stated that she is taking this antibiotic because she has an abscess in her liver. On 3/25/25 at 2:43 PM, R81's morning nurse was V4 (RN-Registered Nurse). She stated that the IV antibiotic was infused over the night shift at 6:00 AM by V5 (RN). V4 stated, The IV bag should have been labeled with the date, time, flow rate, and room number. On 3/27/25 at 10:24 AM, V2 (ADON-Assistant Director of Nursing) stated, The nurses need to make sure all information related to the antibiotic is on the IV bag. This includes the patient's name, what medication it is, when they started the medication, the rate, and start time.…
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 before2025-03-28 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure medications are labeled and stored securely. This applies to 8 of 8 residents (R5, R8, R19, R35, R81, R101, R102 and R247) reviewed for medication storage in a sample of 24. 1. On 03/27/25 at 12:51 PM, a first-floor medication cart was reviewed with V10 LPN (Licensed Practical Nurse). The hydrocodone- acetaminophen 5/325 mg (Milligram) medication card for R101 had one tablet blister that had been taped closed. The medication card had a count of 30 tablets. R101's current physician orders include hydrocodone- acetaminophen 5/325 mg one tablet every four hours as needed for pain. V10 LPN stated once the blister is opened it should be wasted not taped back, but she was not sure why it should not be taped. V10 stated she was one of the nurses that did the narcotic count for that cart, but she did not look at the back of the medication cards when she did the count. 2. On 03/27/25 at 12:51 PM, the pregabalin 25 mg medication card for R102 one tablet blister that had been taped closed. The medication card had…
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 before2025-03-28 · 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
Based on observations, interviews, and record reviews, the facility failed to implement infection control measures while providing resident care and with the handling of soiled linen. This applies to 6 out of 7 residents (R3, R6, R47, R77, R15, R72) reviewed for infection control in a sample of 24. The findings include: 1. On 03/25/25 at 01:08 PM during lunch service, V13 (Nurse) wiped food off R3's mouth with her right hand and then uses the same right hand and puts a spoonful of food into R47's mouth. V13 did not clean her hands after wiping R3's mouth. From 01:08 PM - 01:23 PM V13 was observed using both her right and left hand to assist R3 and R47 with eating their lunch. Both R3 and R47 were sitting at the same table and V13 never cleaned her hands between each resident for the entire meal. V13 used her left hand to give R3 a drink and then V13 used her right hand to touch R47's hand to stop her from putting a bite of food into her mouth, then went back to feeding R3 with her right hand. On 03/27/25 at 01:00 PM V2 ADON (Assistant Director of Nursing) said that V13 should have…
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 · D2025-03-28 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and record reviews, the facility failed to ensure residents were treated with dignity while providing care. This applies to 2 of 2 residents (R3 and R47) reviewed for dignity in a sample of 24. The findings include: On 03/25/25 at 12:49 PM, V13 (Nurse) was standing over R3 while feeding R3 her lunch. At 01:17 PM, V13 was standing over R47 while feeding R47 her lunch. At 01:23 PM, V13 comes back to R3 and again V13 is standing over R3 while feeding R3 her lunch. On 03/27/25 at 01:00 PM, V2 ADON (Assistant Director of Nursing) said that V13 should not be standing over a resident while feeding them. V2 said that V13 should be at the same eye level as the resident for dignity, and safety, and it makes the residents feel more comfortable and respected. R3's 3/2/25 electronic health records showed that R3 needs partial/moderate assistance from staff for eating and her cognition is severely impaired. R47's 1/10/25 electronic health records showed that R47's cognition is severely impaired, and the record showed that R47 is totally dependent on staff for…
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 · D2025-03-28 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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 provide the resident and/or their representative of the facility bed hold policy in writing. This applies to 1 of 1 resident (R75) reviewed for discharge in a sample of 24. The findings include: R75's Face Sheet showed R75 was admitted to the facility on [DATE]. R75 had multiple diagnoses which included acute chronic diastolic (congestive) heart failure, restlessness and agitation, hypertension, and asthma. R75's MDS (Minimum Data Set) dated 03/16/25 showed R75 had moderate cognitive impairment. R75's progress notes dated 11/02/24 at 2:08 AM, showed At 1:20 AM, the nurse heard resident asking for help. The nurse entered the room and observed R75 sitting at the edge of the bed. He stated, I'm having a hard time breathing. The nurse started immediately obtaining his vitals. Spo2 (oxygen) was 77. 911 was called. Will call the hospital to obtain an admitting diagnosis. 11/02/24 at 2:25 AM, admitted to (Hospital) per nurse. Admitting dx (diagnosis) of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-28 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to provide ADL (Activities of Daily Living) assistance for residents who require assistance to maintain their cleanliness and comfort. This applies to 3 of 5 residents (R14, R46 and R395) reviewed for ADLs in a sample of 24. Findings include: 1. On 03/25/25 at 11:45 AM, R395 stated he has not been washed up since he entered the facility on 3/21/25. R395 stated he gets sweaty, and his gown sticks to his skin. R395 had a full-face beard. R395 stated he is not a beard guy. R395 stated he is itchy and uncomfortable with the facial hair. R395 stated he has asked staff for assistance, but they have not shared their names and when staff comes in his room, he feels like he is bothering them. On 03/27/25 at 09:13 AM, R395 still had a full beard and smelled of body odor. On 03/27/25 at 10:06 AM, V19 CNA (Certified Nursing Assistant) stated he did not know he was assigned to R395. V19 stated he was working a double shift, but the current shift started at 7am. V19 stated he needed to check the assignment board at the desk.…
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 before2025-03-28 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow physician's orders and subsequently a colonoscopy had to be rescheduled. This applies to 1 of 3 residents (R23) reviewed for following physician's orders for outpatient procedures. The findings include: R23 was scheduled for a colonoscopy and an EGD (Esophagogastroduodenoscopy) on 03/19/25 per the procedure reminder form sent from the gastroenterology office on 03/14/25. The form showed to hold Eliquis [blood thinner] two days prior to the procedure. R23's MAR (Medication Administration Record) for 03/2025 showed R23 was administered a blood thinner on 03/17/25 at 9:00 AM and 5:00 PM. R23's progress notes dated 03/19/25 at 2:17 PM, showed Resident unable to complete colonoscopy d/t (due to) inability to get IV (intravenous) placed. OBC to MD (Medical Doctor), awaiting return call back . On 03/21/25 at 8:44 AM, V23's (Medical Doctor), Physician Progress note showed diarrhea d/t colon prep. HX (History) of colon cancer. Colon scope not performed,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 19 citations
- Potential for harm · Dcited before2025-01-16 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to send a resident to the hospital emergency department via 911 after a change in condition. This applies to 1 of 3 residents (R1) reviewed for change in condition in the sample of 6. The findings include: R1 was originally admitted to the facility on [DATE] with multiple diagnoses including traumatic subdural hemorrhage with loss of consciousness of unspecified duration, unspecified fracture of the fifth lumbar vertebrae with delayed healing, type 2 diabetes mellitus without complications, cognitive communication deficit and need for assistance with personal care, based on the face sheet. R1's blood specimen obtained on December 30, 2024 for CBC (complete blood count) showed that the resident's WBC (white blood cell) was 17.92 (normal range 4.80-10.80), hemoglobin was 10.4 (normal range 12.0-16.0), hematocrit was 32.3 (normal range of 37.0-47.0). R1's progress notes dated December 30, 2024 at 3:16 PM, created by V3 (Primary Care Physician) showed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-18 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a resident was free from sexual abuse. This applies to 1 of 3 residents (R1) reviewed for sexual abuse in the sample of 4. The findings include: R1's face sheet shows she is a [AGE] year old Spanish, American Indian woman. Her diagnoses are listed to include: paraplegia, need for assistance with personal care, depression, third degree burn to right toe & cellulitis to right lower limb. The facility's abuse report final form dated December 11, 2024 shows, sexual abuse to R1 by V3 (Kitchen Aide). (V4-Receptionist) reported to (V1-Administrator) that resident was upset about possible discharge. (R1) then stated that maybe it is because one of the kitchen staff (V3) kissed her and touched her chest sometime on 11/15/2024. On December 17, 2024 at 10:13 AM, R1 was lying in bed watching television. She stated, she exchanged her phone number with V3 (Kitchen Aide) who worked at the facility. They originally shared phone numbers until V3…
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 · D2024-12-18 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to follow their abuse policy by completing background checks on 1 of 3 new hires, (V3), reviewed for background checks. This applies to all residents residing in the facility. The findings include: The facility data sheet dated December 17, 2024 shows, there are 99 residents residing in the facility. On December 17, 2024 at 4:00 PM, V1 (Administrator) stated, V3 (Kitchen Aide) was hired at the facility on February 20, 2022. The Illinois State Police background check for V3 (Kitchen Aide) was done on December 9, 2024 (almost 3 years later). The result is no record on file. The Illinois Department of Public Health (IDPH), Health Care Worker Registry (no date) with V3's (Kitchen Aide) social security number shows, no workers found. Another IDPH Health Care Worker Registry (no date) shows, V3 (Kitchen Aide) is eligible to work and had a fee_app (fingerprint) on December 11, 2024. On December 17, 2024 at 2:04 PM, V1 (Administrator) stated, when the allegation of V3 (Kitchen Aide) came about they checked his file. They could not…
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 · E2024-06-24 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain resident room air temperatures at a comfortable temperature. This applies to 9 of 9 residents (R1-R8 and R11) reviewed for homelike environment in a sample of 11. The findings include: 1. The electronic medical record showed R1 was admitted to the facility on [DATE]. On 6/20/24 at 11:22 AM, V5 (R1's Family) stated This room is too hot! V5 stated she complained that the room was hot since R1 moved into the facility but the room remained hot. R1 and R2 stated the room had been too hot for days. There was cool air slowly blowing from the air conditioning unit in the room, but the room was very warm and felt very humid and felt much warmer than the hallway air temperature. V3 (Maintenance) stated he replaced and flushed the air conditioner unit water lines the prior week. Facility Concern/Response Form, dated 6/20/24, shows V5 expressed concern that R1's room was too warm and there was not enough circulation in the room. The form…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-23 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents' call lights were within their reach for 2 of 4 residents (R3 and R4) reviewed for call lights in the sample of 4. The findings include: On 4/23/24 at 10:58 AM, R3 was sitting in her wheelchair in her room. R3's wheelchair was positioned next to the left side of her bed toward the middle of the bed. R3's call light was wrapped around the upper left side rail which was to the right and behind her. R3 was unable to reach her call light. On 4/23/24 at 11:08 AM, R4 was sitting in her wheelchair in her room watching TV. R4's call light was behind her lying on the night stand. R4 said she uses her call light when she needs to call for help. R4 was unable to reach her call light. On 4/23/24 at 10:41 AM, V3, Licensed Practical Nurse (LPN), said staff keep the residents' call light in reach and residents should always have their call light. On 4/23/24 at 11:18 AM, V4, Certified Nursing Assistant (CNA), said the residents are 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.
- Potential for harm · E2024-02-01 · tag F0583 — failed to protect personal privacy — patternKeep 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, interview, and record review, the facility failed to provide personal privacy during provisions of Activities of Daily (ADL) care. This applies to 4 of 6 residents (R40, R11, R22, and R7) reviewed for privacy in the sample of 20. The findings include: 1. On January 30, 2024, at 9:58 AM, V4 (Certified Nursing Assistant/CNA) assisted R40 with ADL care. V4 removed R40's clothes to render incontinence care. R40 was wet with urine and had a bowel movement. During the process of care, V4 went back and forth to the bathroom multiple times to change her gloves and perform hand hygiene, leaving R40 totally naked in bed. In addition, V4 did not close the window curtain and draw privacy curtain all throughout the care. Though R40's roommate was not in the bedroom, he could have come in anytime. 2. On January 30, 2024, at 10:42 AM, V4 (CNA) assisted R11 to the bathroom for toileting care. The bathroom was located by the entrance of the bedroom. V4 did not close the bedroom door or the bathroom door while R11 was using the toilet. R11's roommate (R40) was inside the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-02-01 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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 assist residents identified as needing assistance with personal hygiene and oral care. This applies to 4 of 10 residents (R7, R14, R16, R17) reviewed for ADL (Activities of Daily Living) care in the sample of 20. The findings include: 1. R14's face sheet included diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, anxiety disorder, unspecified, altered mental status, hyperosmolality and hypernatremia, and history of falling. R14's quarterly MDS (Minimum Data Set), dated November 23, 2023, showed R14 is severely impaired in cognition, and required substantial/maximal assistance in oral care and personal hygiene. R14's care plan, initiated July 21, 2023, included R14 requires assistance with ADLs which included personal hygiene. Goal for the same included resident will be assisted with ADLs as needed through the review date of February 11, 2024. On January 29, 2024, at 12:59 PM, R14 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 · Ecited before2024-02-01 · 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 Based on observation, interview, and record review, the facility failed to follow their policy for Enhanced Barrier Precautions. The facility also failed to follow their policy for hand hygiene and glove use during provisions of care. This applies to 6 of 20 residents (R7, R17, R22, R44, R58, and R80) in the sample of 20. The findings include: 1. The EMR (Electronic Medical Record) showed R80 was admitted to the facility on [DATE], with multiple diagnoses including chronic respiratory failure, stroke, dysphagia, and gastrostomy status. R80's MDS (Minimum Data Set), dated November 23, 2023, showed R80 had a feeding tube. R80's Order Summary Report, dated January 31, 2024, showed the following order dated September 30, 2023, Isolation Reason: Enhanced Barrier Precautions related to g-tube (gastrostomy tube) and trach (tracheostomy). On January 31, 2024, at 11:27 AM, V13 (RN/Registered Nurse) entered R80's room. R80's door had a sign posted titled Enhanced Barrier Precautions. V13 did not perform hand hygiene upon…
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 · E2024-02-01 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were offered pneumococcal vaccination in accordance with their policy and CDC (Center for Disease Control) guidelines. This applies to 5 of 9 residents (R7, R26, R29, R32, and R46) reviewed for immunizations in the sample of 20. The findings include: 1. The EMR (Electronic Medical Record) showed R7 was [AGE] years old. R7 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, diabetes type 2, and hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non dominant side. R7's immunization record showed R7 had not been offered nor received any pneumococcal vaccine since admission, prior to January 13, 2024. R7 had consented to receive the vaccine on January 13, 2024, but as of January 31, 2024, had not received the vaccine. On January 31, 2024, at 1:40 PM, V12 (Infection Preventionist) stated there is no documentation to show R7 had previously 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.
- Potential for harm · D2024-02-01 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility also failed to ensure medication was not left at a resident's bedside for self-administration without a self-administration assessment and a physician's order. This applies to 1 of 20 residents (R2) reviewed for quality of care in the sample of 20. The findings include: 1. R2's face sheet included diagnoses of chronic obstructive pulmonary disease (COPD), chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, and anxiety disorder. R2's Medicare End of PPS Part A Stay MDS (Minimum Data Set), dated December 17, 2023, showed R2 was cognitively intact. R2's POS (Physician Order Sheet) for January 29, 2024 included Albuterol Sulfate HFA [hydro fluoroalkane) Inhalation Aerosol Solution 108 (90 Base) MCG/ACT [micrograms/actuation] (Albuterol Sulfate) puff inhale orally four times a day for treatment (start date November 26, 2023). The same POS did not include whether R2 can self-administer this medication. R2's care plan, initiated November 5, 2023, included R2 is at risk for alteration in respiratory…
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 before2024-02-01 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure that one resident's ace wraps to his legs were applied according to doctor's order. This applies to 1 of 20 residents (R24) reviewed for quality of care in the sample of 20. The findings include: 1. R24's Physician order, dated November 16, 2023, shows the following: wraps to bilateral lower extremity (BLE) for compression in the morning for edema and remove per schedule. R24's Care plan documents R24 has potential impairment to skin integrity related to impaired mobility, incontinence, impaired circulation, impaired cognition, skin fragility related to age, psychotropic medication uses and diagnoses of Parkinson's, Chronic Kidney Disease, Congestive Heart Failure, Dementia, Anemia, Obesity, Peripheral Artery Disease, Venous insufficiency, and Hypertension. This Care Plan includes the following intervention dated June 15, 2023: wraps to bilateral lower extremity for compression. On January 29, 2024, at 11:23 AM, R24 was sitting in a wheelchair in his room and his legs were not wrapped. R24's bilateral…
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 · D2024-02-01 · 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 the indwelling urinary catheter tube was secured to the resident to prevent potential tugging or pulling. This applies to 3 of 4 residents (R7, R22, and R57) reviewed for urinary catheter care in the sample of 20. The findings include: 1. On January 30, 2024, at 12:45 PM, V4 (Certified Nursing Assistant/CNA) emptied R22's urinary catheter bag with 750 ml output. V4 proceeded to render peri-care. During the provisions of care, it was noted R22's urinary catheter tube was not secured to R22. It was moving freely and unsecured from side to side and was in between her buttocks while being repositioned. 2. On January 30, 2024, at 1:22 PM, V5 (CNA) rendered incontinence care to R57. During provisions of care, it was observed R57's urinary catheter was not anchored to R57. The urinary catheter tube was pulling during incontinence care and repositioning. 3. On January 30, 2024, at 1:48 PM, V6 (CNA) rendered incontinence care to R7, who had indwelling urinary catheter. The catheter tube was not anchored to R7.…
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 · D2024-02-01 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to check placement and flush a gastrostomy tube prior to enteral feeding, and to position a resident in fowler's position during enteral feeding. This applies to 2 of 5 residents (R80 and R58) reviewed for tube feeding in the sample of 20. The findings include: 1. The EMR (Electronic Medical Record) showed R80 was admitted to the facility on [DATE], with multiple diagnoses including chronic respiratory failure, stroke, dysphagia, and gastrostomy status. R80's MDS (Minimum Data Set), dated November 23, 2023, showed R80 had a feeding tube. R80's enteral feeding care plan, dated August 29, 2023, showed, [R80] requires enteral feedings as the primary source of nutrition, due to the following conditions and risk factors: dysphagia. The care plan continued to show multiple interventions dated August 29, 2023, including Monitor for complications: aspiration, diarrhea, respiratory infection, dehydration, abdominal pain, feeding tube displacement,…
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 · D2024-02-01 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
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 administer medications as ordered. There were 25 opportunities and 2 errors, resulting in an 8% medication error rate. This applies to 1 of 5 (R30) residents reviewed for medication administration in the sample of 20. The findings include: The EMR (Electronic Medical Record) showed R30 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, myocardial infarction, schizophrenia, unspecified and bipolar disorder. R30's order summary showed Fexofenadine HCL (Hydrochloride) 180 mg (milligrams), one time a day, order initiated on January 3, 2024, for allergy and Gabapentin 100 mg give 200 mg three times a day at 9:00 AM, 2:00 PM, and 6:00 PM for epilepsy, order initiated on January 3, 2024. On January 29, at 12:26 PM, V10 (RN/Registered Nurse) was preparing to administer R30's medication scheduled for 9:00 AM. V10 stated Gabapentin 100 mg tablets and Fexofenadine HCL 180 mg were not…
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 · D2023-03-03 · 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 ensure that expired medications are removed from use. This applies to 1 of 5 residents (R55) reviewed for insulin storage, labeling, and administration in a sample of 22. The findings include: On 3/1/23 at 11:45 AM, two medication carts were reviewed with V3, LPN (Licensed Practical Nurse). During review, R55's Novolog insulin vial was found with open date of 1/28/23. V3, LPN, said R55's Novolog is expired, and threw the vial in the sharps container. V3, LPN, said Novolog insulin vials expire 28 days after opening. R55's Novolog insulin vial expiration date was 2/25/23. On 3/2/23 at 10:45 AM, V3 said R55 only has one Novolog insulin vial stocked in the medication cart for use at a time. V3 said the expired Novolog insulin vial that she threw in the sharps container on 3/1/23 at 11:45 AM was the same vial used since open date 1/28/23 to administer Novolog insulin to R55. On 3/1/23 and 3/2/23 V2, ADON (Assistant Director of Nursing), and V4, LPN, said expired insulin is not as effective in lowering elevated…
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 · D2023-03-03 · 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 apply splint/rolled towel and heel protectors to prevent further decrease in range of motion. This applies to 2 of 2 residents (R11 and R19) reviewed for range of motion in a sample of 22. The findings include: 1. On 02/28/23 at 11:03 AM, R11 was observed not wearing a hand splint, and did not have a rolled towel on left hand. R11's left hand was in a bent position and R11 was not able to open left hand. On 03/01/23 at 09:42 AM, R11 was observed with no hand splint and no rolled towel on left hand. On 03/02/23 10:59 AM, skin check done with V11 (Restorative Nurse). R11 was not wearing any splint or rolled towel on left hand. On 03/02/23 at 09:46 AM, interview with V11 (Restorative Nurse) stated R11 should have hand splint/ rolled towel on left hand. V11 stated R11 is on Restorative Program for splints. V11 stated R11's splints/rolled towel should be applied in the morning and taken off at bedtime. R11's Care Plan, dated 2/14/2023, shows he is on splint program with goal to be able to tolerate use of splints.…
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 before2023-03-03 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to monitor and maintain PICC (Peripherally Inserted Central Catheter) line dressings that were dirty and not occlusive. This applies to 2 of 2 (R79, R289) residents reviewed for PICC lines in a total sample of 22. Findings include: 1. R79's face sheet documents diagnoses including compression fracture of the lumbar vertebra, sepsis, and osteomyelitis of vertebra. R79's MDS (Minimum Data Set), dated 2/2/2023, showed R79 was cognitively intact. R79 requires extensive assistance from staff for bed mobility, transfers, dressing, toileting, and personal hygiene. On 2/28/2023 at 9:57 AM, R79's PICC line dressing was not occlusive on R79's skin. R79's dressing was lifting 1 inch on the bottom right corner, and the tubing was observed to be exposed to air. R79's PICC line did not have a disinfection cap at the end of the needless connector. R79 said the PICC line dressing was last changed two weeks ago. On 3/2/2023 at 1:04 PM, R79 said, They've…
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 · D2023-03-03 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow physician orders for pain management and assessment. This applies to 1 of 3 residents (386) reviewed for pain management in a sample of 22. Finding includes: On 11/22/2022 at 11:08 AM, R386 indicated he wanted to take his Tylenol #3 medication for pain for three days since the admission to the facility on [DATE], and he has been asking staff, with no help. R386 said he has been taking Tylenol #3 for 30 years for his chronic pain. R386 said he was recently admitted to the hospital with severe abdominal pain before coming to the facility and received Tylenol #3 at the hospital also. R1 said he feels he has a 10 out of 10 pain rating (10 indicates highest pain) most of the time in his shoulder, back, and sometimes in his legs due to spinal stenosis of the back, kidney injury, and gallbladder stone-related conditions. On 03/01/2023 at 11:19 AM, R386 said he asked for Tylenol #3 at night and in the morning around 7:30 AM, and still didn't get it.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-03 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assure that medications were secured. This applies to R49 and R289 reviewed for medication storage in a sample size of 22. 1. R289 was admitted to the facility on [DATE] per current Physician's Order Sheet, with diagnoses to include, but is not limited to, cellulitis of the right lower limb, pseudomonas, lymphedema, and chronic lymphatic leukemia. On 2/28/23 at 12:11 PM, a half- filled bottle of Cefuroxime 500mg, dated 12/09/22, was on top of R289's bedside table. On 3/2/23 at 9:50 AM, R289 was still in possession of the bottle of Cefuroxime. On 3/2/23 at 10:12 AM, V13, RN (Registered Nurse), stated R289 did not have an assessment to keep medications at his bedside. Residents are not typically allowed to keep their medications at the bedside. On 3/2/23 at 10:23 AM, V14, Nurse Consultant, stated there should not be any medications left at bedside. If a resident was going to have medications at the bedside, they would need an assessment 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to LEGACY HEALTHCARE — 89 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.9 | +1.1 vs chain |
| Health inspection | 4 of 5 | 2.8 | +1.2 vs chain |
| Staffing | 2 of 5 | 2.5 | -0.5 vs chain |
| Quality measures | 3 of 5 | 3.3 | -0.3 vs chain |
The other 88 homes this chain runs (chain average 2.9★, per CMS)
Showing 40 of 88; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| DOROS GENERATION TRUST U/A/D 1/3/12 | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 17% | since 06/01/2021 |
| GPN FAMILY TRUST U/A/D 4/28/08 | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 17% | since 06/01/2021 |
| GARDEN, DANIEL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 8% | since 06/01/2021 |
| NINIO, MORDECHAY | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 8% | since 06/01/2021 |
| MUNDT, BONNY | Individual | W-2 MANAGING EMPLOYEE | — | since 06/01/2021 |
| TBDMD IL, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 06/01/2021 |
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $220K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145737. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-28, 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.