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Avantara Long Grove

1666 Checker Road, Long Grove, IL 60047 · For profit - Corporation · 195 certified beds · (847) 419-1111 Medicare & Medicaid certified

Call the home — (847) 419-1111 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 25 lower-level deficiencies on record (see below)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • 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
  • lower-than-typical staff turnover (35% vs 45% nationally) — better care continuity
Worth asking about
  • a high number of inspection citations overall (25) — 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)
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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.

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
135 N Arlington Heights Rd · (224) 345-2532 · Call to confirm hours
Pharmacy
1160 W Lake Cook Rd · (847) 537-3203 · Call to confirm hours
Grocery
302 Old McHenry Rd · (847) 383-6414 · Call to confirm hours
Park
1300 Weiland Rd, Buffalo Grove, IL 60089 · (847) 850-2100 · Typically dawn to dusk
Place of worship
1670 Checker Rd · (847) 537-1771

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 4 to 5 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating5★
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 increased5.4%13.4%15.4%better
Long-stay residents who lose too much weight7.3%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 symptoms92.0%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 injury2.9%3.1%3.3%better
Long-stay residents whose ability to walk worsened8.7%14.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication15.0%18.3%18.9%better
Long-stay residents given the seasonal flu vaccine99.3%91.8%95.3%typical
Long-stay residents with pressure ulcers4.7%4.8%4.7%typical
Long-stay residents with worsening bladder/bowel control23.4%20.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table11.3%21.7%17.1%better
Short-stay residents who newly got an antipsychotic medication1.6%2.2%1.4%worse
Short-stay residents given the seasonal flu vaccine80.0%63.1%79.4%typical
Short-stay residents rehospitalized after admission24.9%26.1%22.6%typical
Short-stay residents with an outpatient ER visit12.5%13.9%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.382.021.67better
Long-stay outpatient ER visits per 1,000 resident days1.582.221.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

50.1% 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 268 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

50.1%U.S. median 51.5%
Got home and stayed home
9.2%U.S. median 10.7%
Went back to hospital
73.9%U.S. median 56.6%
Met the expected recovery
0.29U.S. median 0.31
Therapy hours / resident / day
0.16hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 73.9% 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 92 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 0.29 therapist hours per resident per day in 2026Q1 — more than 44% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 40% 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 SNF50.1%CMS range 44.5–55.351.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.2%CMS range 6.4–11.910.7%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 discharge73.9%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 discharge79.3%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 discharge68.5%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 identified98.7%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 setting100.0%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 discharge100.0%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 stay1.3%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 worsened0.7%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 hospitalization8.2%CMS range 5.5–10.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.291.02Oct 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

0.71
RN hours/ resident / day
0.64
LPN hours/ resident / day
1.76
Aide hours/ resident / day
3.11
Total nurse hours/ resident / day
0.68
RN hoursweekends
34.6%
Total nursing turnover
27.6%
RN turnover

How full it usually is: this home is certified for 195 beds and averages 176.6 residents a day — about 91% occupied, or roughly 18 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 3.11 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.71 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.76 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.96 hrs/resident/day on weekends vs 3.18 on weekdays — 7% thinner on weekends. RN hours go from 0.72 to 0.68 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 35% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

8
deficiencies at the latest standard inspection (2024-08-08)
7
at the previous standard inspection (2023-06-28)

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.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

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.

25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.

  • Potential for harm · Dcited before2025-01-22 · 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 identify a fall for a resident with a history of falling and failed to implement their fall policy for 1 of 3 residents (R1) reviewed for safety/supervision in the sample of 3. The findings include: On 1/22/25 at 9:41 AM, R2 had self-propelled from the dining room area, in her wheelchair. R1 was in the dining room, watching R2 leave. R1 had a clothing protector on his chest, and it fell to the floor. R1 was in a high back wheelchair, with no foot pedals. R1 reached forward and tried to pick up the clothing protector from the floor. There was not a staff member inside the dining room area. V4 (RN -Registered Nurse) was at the medication cart, outside the dining room, looking down. R1 continued to reach for the clothing protector and his buttocks came off the seat of his wheelchair. The surveyor informed V4 (RN) that R1 was reaching for something on the floor and was concerned he may fall. V4 instructed R1 to stop reaching and stated, He'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-08-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    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 ensure residents were free of accidental hazards by not removing razors from the room of residents with dementia and within reach of residents that have dementia that wander. This applies to 2 of 2 residents (R49 & R120) reviewed for safety in the sample of 32 and 8 residents (R79, R96, R103, R109, R119, R127, R142, & R149) outside of the sample. The findings include: On 8/6/24 at 12:51 PM, in the bathroom of room [ROOM NUMBER] there was a disposable razor in a clear plastic bag on the mirror ledge. The safety cover was off of the dry razor. R49 was one of two residents that resided in room [ROOM NUMBER]. On 8/7/24 at 9:45 AM, in the bathroom of room [ROOM NUMBER] there was a disposable razor in a clear plastic bag on the mirror ledge. The safety cover was off of the dry razor. The Face Sheet dated 8/7/24 for R49 showed diagnoses including dementia, delirium, paroxysmal atrial fibrillation, lack of coordination, congestive heart failure,…

    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 · E2024-08-08 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    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 bedtime snacks were offered to residents for 3 of 3 residents (R58, R112, and R526) reviewed for bedtime snacks in the sample of 32 and one resident (R1) outside of the sample. The findings include: R58's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include generalized osteoarthritis, anemia in other chronic diseases, hypothyroidism, hyperlipidemia, and depression. R58's August 2024 Physician Order Sheet showed, 8/5/23 Offer Bedtime Snack. R58's Nutrition-Snacks documentation for the last 30 days was reviewed and showed he was offered a snack two times. R526's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include seizures, dysphagia, Type 2 Diabetes Mellitus, and hypertensive heart disease. R526's August 2024 Physician Order Sheet showed, 7/26/24 Offer Bedtime Snack. R526's Nutrition-Snacks documentation since admission to the facility was reviewed and showed no snacks offered.…

    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 · Ecited before2024-08-08 · tag F0880 — failed to prevent and control infections — pattern
    Provide 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 implement contact isolation precautions for a resident (R95) with methicillin-resistant Staphylococcus aureus (MRSA), failed to wear the appropriate personal protective equipment (PPE) for 3 residents (R31, R11, R154) on enhanced barrier precautions, and failed to perform glove changes during incontinence care for 1 resident (R154). These failures apply to 4 of 9 residents reviewed for infection control in the sample of 32. The findings include: 1. R95's electronic face sheet printed on 8/8/24 showed R95 has diagnoses including but not limited to fracture of head and neck of right femur, sepsis, osteomyelitis, pressure ulcer of sacral region, stage 4, flaccid hemiplegia, post laminectomy syndrome, and cord compression. R95's physician's orders dated 8/1/24 showed, Isolation: contact precautions, reason for isolation MRSA sacral wound. R95's care plan dated 4/13/24 showed, (R95) is on isolation. Contact isolation due to MRSA of sacral…

    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 · D2024-08-08 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide dignity during personal cares for 2 of 2 residents (R31, R97) reviewed for dignity in the sample of 32. The findings include: 1. R31's electronic face sheet printed on 8/8/24 showed R31 has diagnoses including but not limited to multiple sclerosis, pressure ulcer of left buttock unstageable, non-pressure chronic ulcer of right heel and midfoot, major depressive disorder, peripheral vascular disease, and dysphagia. R31's facility assessment dated [DATE] showed R31 has mild cognitive impairment. On 8/6/24 at 10:26AM, V13 (Certified Nursing Assistant) provided incontinence care to R31. R31 was rolled onto her left side with her buttocks uncovered, facing the window. R31's window had clear exposure to the parking lot where people could be seen walking by vehicles within view of R31's window. V13 stated, We don't close her blinds because she doesn't like the dark room. Normally we would but for her we don't. R31 then stated, It bothers…

    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 · Dcited before2024-08-08 · 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

    Based on interview and record review, the facility failed to obtain weights as ordered by a physician for 1 of 2 residents (R34) reviewed for quality of care in the sample of 32. The findings include: R34's electronic face sheet printed on 8/8/24 showed R34 has diagnoses including but not limited to hemiplegia and hemiparesis, chronic respiratory failure, dysphagia, hypertensive heart disease, and heart failure. R34's physician's orders dated 3/26/21 showed, Weekly weights: monitor for increased edema notify MD for weight gain of 5lbs in a week. R34's monitor record showed R34's weight was not obtained on 7/19/24, 7/28/24, and 8/2/24. R34's care plan dated 4/5/24 showed, Risk for fluctuating weights: (R34) has the following conditions and risk factors that put them at risk for fluctuating weights: diuretic use and diagnosis of heart failure .monitor weights per physician's orders. On 8/8/24 at 11:11AM, V11 (Clinical Care Coordinator) stated, Weights for residents are done on a monthly basis and as ordered by a physician. The nurses can see on the monitoring record when residents are…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-08 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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 an indwelling urinary catheter drainage bag was not placed on a resident's bed or lifted above the level of the resident's bladder for 1 of 4 residents (R53) reviewed for catheters in the sample of 32. The findings include: On 8/7/24 at 1:52 PM, V4 CNA and V5 CNA went into R53's room to provide catheter care. V5 completed the catheter care and put a clean incontinence pad and incontinence brief under R53. V5 lifted the drainage bag and laid it on R53's bed. V4 picked up the drainage bag, held it up above the level of the resident's bladder as she moved the bag to his left side of the bed and attached it to the side rail. V4 and V5 adjusted the incontinence brief and incontinence pad under part of the resident's bottom. V5 turned R53 towards her. V4 unhooked the drainage bag from the side rail, lifted the drainage bag approximately a foot above the resident's bladder as she passed it over to V5 who attached the bag to his lower right side of the bed. V5 stated the drainage bag shouldn't be placed on 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-08 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to administer oxygen as ordered by a physician for 3 of 4 residents (R34, R95, R519) reviewed for oxygen therapy in the sample of 32. The findings include: 1) R34's electronic face sheet printed on 8/8/24 showed R34 has diagnoses including but not limited to hemiplegia and hemiparesis, chronic respiratory failure, dysphagia, hypertensive heart disease, and heart failure. R34's facility assessment dated [DATE] showed R34 receives oxygen therapy. R34's physician's orders dated 11/23/21 showed, Oxygen at 2L/min (liters per minute) via nasal cannula at bedtime. R34's care plan dated 7/1/19 showed, (R34) is on oxygen therapy related to ineffective gas exchange, heart failure. She is on oxygen continuous on 2L/min (liters per minute) via nasal cannula .give oxygen as ordered by the physician. On 8/6/24 at 10:18AM, R34 was in bed sleeping with her oxygen applied via nasal cannula. The oxygen concentrator was set at 3 liters. On 8/8/24 at 10:57AM,…

    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 · Dcited before2024-08-08 · tag F0755 — failed to provide safe pharmacy services — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure physician prescribed medications were administered as ordered for 1 of 2 residents (R1) reviewed for medication administration in the sample of 32. The findings include: R1's face sheet printed on 8/8/24 shows diagnosis including but not limited to neuropathy, heart disease, asthma, schizoaffective disorder, dysphagia, gout, anemia, depression, pancreatitis, diabetes mellitus, and functional quadriplegia. R1's facility assessment dated [DATE] showed no cognitive impairment or memory problems. On 8/6/24 at 11:04 AM, R1 was seated in a wheelchair in his room. Four medication cups were on the bedside table next to him. One cup contained a blue liquid, one contained three capsules, one contained a single blue tablet, and one contained six assorted colored tablets. R1 stated the nurse dropped those off a while ago. They are my 9:00 medicines. I asked her to just leave them. They do it all the time. R1's MAR (medication administration…

    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 · Dcited before2024-05-14 · 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 Based on observation, interview and record review the facility failed to ensure a resident with eczema was assessed and treated in a timely manner. This applies to 1 of 6 residents (R1) reviewed for quality of care in the sample of 6. The findings include: On May 14, 2024, at 10:10 AM, R1 was lying in bed. The entire top of her head/scalp was dry with yellow/red crusty scabs. Her hair appeared greasy and/or wet. She stated, They say it's eczema on my head. It's been there for a while. On May 14, 2024, at 10:56 AM, V3 Certified Nursing Assistant (CNA) stated, R1's head has been like that for 2-3 months. They are not doing anything for it. She has been putting A&D ointment on it until R1's friend (V5 power of attorney of financial (POA)) brought her a medicated shampoo. She was washing her hair with regular shampoo, but it was drying it out more. She didn't know what it was on her head. It started off small and has gotten bigger. When she tries to scrape off the crusty scabs, R1 says it hurts so she doesn't scrub…

    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
Show the remaining 15 citations
  • Potential for harm · Dcited before2024-01-11 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide oxygen therapy according to professional standards for a resident (R1) experiencing low oxygen levels. This applies to 1 of 3 residents reviewed for oxygen therapy in the sample of 4. The findings include: R1's electronic face sheet printed on 1/10/24 showed R1 has diagnoses including but not limited to surgical amputation, chronic respiratory failure with hypoxia, generalized anxiety disorder, peripheral vascular disease, congestive heart failure, and ischemic cardiomyopathy. R1's facility assessment dated [DATE] showed R1 had mild cognitive impairment, respiratory failure, and heart failure. R1's care plan dated 1/2/24 showed, (R1) has an altered respiratory status/difficulty breathing related to chronic respiratory failure .give oxygen as ordered by the physician, elevate head of bed, monitor/document/report abnormal breathing patterns to physician . R1's nursing progress notes dated 1/5/24 showed, This writer was attending to resident'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-02 · 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 supervise a resident with dementia and a history of wandering for 1 of 9 residents (R2) reviewed for safety in the sample of 9. The findings include: On 11/1/23 at 9:45 AM, R2 was sitting in a dining room chair sleeping. R2 had dark purple bruises above his left eyebrow, on his left eyelid, and below his left eye. R2 had gauze wrapped around both hands and wrists. V10 Central Supply was sitting next to R2 and said he was asked to sit with R2 today. On 11/1/23 at 9:52 AM, V6 Licensed Practical Nurse said no one really knows what happened to R2's eye, it happened on the weekend. V6 said R2 wanders around the hallway and goes into other residents rooms. V6 said staff usually follows R2 and redirects him. V6 said R2 has had 1:1 observation since he moved down here from the unit upstairs. V6 said R2 ambulates but can't follow commands and is very confused. V6 said when R2 starts roaming around you really have to watch him. V6 said staff are supposed to be with him at all times when the family is not here. On 11/1/23…

    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 · F2023-06-28 · 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 — the official record, unedited, may be distressing

    Based on observation, interview and record review the facility failed to ensure cookware was handled in a sanitary manner. This applies to all 163 residents residing at the facility. The findings include: The Resident Census and Conditions of Residents Form (CMS-672) dated 6/26/23 shows there were 163 residents residing at the facility. On 6/26/23 at 11:52 AM, V9 (Cook) loaded soiled pans into a tray and ran them through the dishwasher. With the same gloves on, V9 took the cleaned pans from the dishwasher rack and placed them on the storage shelf. On 6/27/23 at 2:00 PM, V8 (Dietary Manager) said that gloves should be removed, and hands should be washed after loading dirty dishes and before touching the clean dishes. The facility's undated Dishwashing Machine Use Policy shows, Wash hands before and after running dishwashing machine, and frequently during the process.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-06-28 · 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 ensure resident rooms were clean and homelike for 4 of 32 residents (R23, R45, R88, R138) reviewed for environment in the sample of 32. The findings include: 1. 06/26/23 10:01 AM R45 was sitting in her room in her wheelchair. R45 stated I've been here 5 weeks. I transferred here from another facility because this place had 5 stars. Housekeeping only comes to clean my room every 2-3 days to sweep and mop. There is a hole in the wall in the bathroom and when I asked when it's being fixed, I was told next year. They last cleaned my room on Friday and haven't been here yet today so probably won't come today. I have accidents. Sometimes I can't help my bladder, so the floor gets dirty. This is 5 stars? R45's floor had various debris scattered around the floor, and several sticky spots. R45's bathroom wall, next to the shower wall had paint off, with the drywall cracked and exposed in plain sight when entering the bathroom. On 06/26/23 at 12:55 AM, R45's floor was still dirty. On 06/27/23 at 8:49 AM, R45 said she…

    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 · D2023-06-28 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    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 R162 was provided with incontinent care as directed by her care plan and failed to ensure R50 was positioned and provided with care planned interventions during mealtimes for two of thirty-two residents reviewed for ADL's-Activities of Daily Living. The findings include: On 06/27/23 at 1:19PM, R162 was lying in bed on her back. R162 had a strong smell of urine. V14 CNA-Certified Nursing Assistant turned R162 without the assistance of another staff. R162 yelled out, made facial grimace, and grabbed her left arm when V14 CNA rolled R162 to her right side by himself. V14 CNA removed R162's incontinent brief, it was saturated with urine and loose stool. R162 had redness to her labia, redness to her right medial thigh, and multiple 1-centimeter red circular areas diffusely spread throughout her inner thighs and posterior buttocks. On 06/27/23 at 1:19PM, V14 CNA said, I last changed R162 at 9:00AM, (over 4 hours). On 06/27/23 at 1:34PM, V4…

    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 · D2023-06-28 · 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 2. On 6/26/23 at 10:29 AM, R147's Pressure reduction heel boots were sitting in a chair at the foot of R147's bed. R147's right and left lateral heels were resting on the bed. No off-loading interventions were in place. On 6/27/23 at 9:03 AM, V18 Restorative Aide said, pressure to the heel of the foot is reduced by elevating the feet off the bed with pillows or applying heel protectors. On 6/27/23 at 11:30 AM, R147 was in bed lying on his back. R147's heels were resting on the bed. R147 did not have heel boots or a pillow to off-load pressure from his heels. R147's current Care Plan on 6/26/23 shows, R147 has potential for pressure injury related to assessed as moderate risk (for pressure ulcers), limited joint mobility, incontinent, diabetes, Cerebral Vascular Accident with hemiplegia, anemia, sacral to groin moisture acquired skin disorder, history of a Stage three pressure ulcer. Intervention: Off-loading of bilateral heel when in bed every shift and as needed. Based on observation, interview and record…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-28 · 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 ensure aspiration precautions were maintained for a resident with dysphagia, failed to provide thicken liquids and failed to ensure fall interventions were in place for a resident at risk for falls. This applies to 2 of 32 residents (R151, R10) reviewed for safety in the sample of 32. The findings include: 1. On 6/26/23 at 9:21 AM, R151 was observed lying in bed during the breakfast meal. The head of the bed was not positioned upright. It was approximately at a 45 degrees angle. A cup of non-thicken orange juice was on his tray half consumed. A bright colored sign was posted on the wall Aspiration Precautions with instructions to have the head of the bed upright. At 12:55 PM, during the noon meal, R151 was positioned at a 45 degree angle. He was served a mechanical ground tray with regular liquids. R151's diet card on his tray shows a mechanical ground and nectar thicken liquids. On 6/27/23 at 1:06 PM, V7 (Certified Nursing Assistant-CNA)…

    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 · Dcited before2023-06-28 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure perineal care was provided in a manner to prevent infections for a resident with a history of urinary tract infections. This applies to 1 of 9 residents (R98) reviewed for bladder services in the sample of 32. The findings include: 1. On 6/26/23 at 9:45 AM, V7(Certified Nursing Assistant) was providing incontinence care to R98. V7 cleansed R98's penile area from the base towards to the tip of the penis and used the same area of the contaminated wipe cleansing his scrotum and groin. On 6/28/23 at 9:33 AM, V2 (Director of Nursing) said staff should be cleansing the top of the penile area downward to prevent infections and should be using a different area of the wipe for cleansing. R98's face sheet shows he is an [AGE] year old male with diagnosis including morbid obesity, chronic kidney disease with heart failure, congestive heart failure, benign prostatic hyperplasia and history of malignant neoplasm of the bladder. R98's care plan…

    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 · D2023-06-28 · 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 ensure a resident with significant weight loss was provided nutritional supplements at meals for 1 of 12 residents (R78) reviewed for weight loss in the sample of 32. The findings include: On 6/26/23 at 12:35 PM, R78 was eating lunch in the dining room. R78 was served puree chicken, mashed potatoes with gravy, puree broccoli, juice, and strawberry ice cream. There was no fortified pudding on R78's tray. On 6/27/23 at 12:45 PM, R78 was eating in dining room. R78 was not served magic up or fortified pudding or ice cream. On 6/27/23 at 1:00 PM, V12 Certified Nursing Assistant said the kitchen is supposed to send up magic cup and fortified puddings on the residents trays. On 6/28/23 at 9:31 AM, V13 Dietician said R78 is on supplements due to poor appetite. The supplements should be given as ordered to help with weight loss. R78's Dietician Note dated 6/13/23 shows R78 significant weight loss times 3 months and 6 months which is unplanned. Current diet regular diet, puree texture, thin liquid, receiving soup 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-04-06 · tag F0805 — failed to prepare food in a form residents can eat — pattern
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, interview and record review the facility failed to ensure the noon meal was thoroughly pureed for 21 of 21 residents (R54, R128, R98, R176, R116, R25, R19, R78, R27, R129, R162, R41, R34, R72, R169, R146, R123, R84, R120, R69 and R107) reviewed for pureed diet in the sample of 35. The findings include: On 04/04/22 at 01:27 PM, the noon pureed meatballs and buttered noodles contained pieces of meat and noodle that required chewing. On 04/04/22 at 01:48 PM, V12 Dietary Manager said puree foods should be smooth with no bits of food to chew. The facility's Puree Diet Type Report dated 4/4/22 shows there are 21 residents in the facility on a pureed diet. The facility's undated Texture Progression Policy shows Pureed: eliminates the need for chewing. All foods must be presented in a form that is homogenous and cohesive in nature foods will be pureed to ensure a smooth cohesive quality without lumps.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-04-06 · 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

    Based on observation, interview, and record review the facility failed to change a non-pressure wound dressing as ordered by the physician for 1 of 3 residents (R162) reviewed for wound care on the sample of 35. The findings include: R162's Order Summary Report showed a dressing order for R162's right foot. The dressing was to be changed daily. The area was to be washed with saline, betadine applied, and covered with a 4x4 gauze and a roll gauze dressing. On 04/04/22 at 9:52 AM, R162 had a roll gauze dressing to his right foot. The edges of the dressing were rolled/curled back onto itself. The date on the dressing was 3/30/22 (5 days old). R162's Treatment Administration Record (TAR) showed R162's right foot dressing was documented as being changed on 4/1/22, 4/2/22, and 4/3/22 by V5 (Wound Care Nurse). On 04/04/22 at 01:44 PM, V5 confirmed the date on the right foot dressing was 3/30/22. V5 said there was a Discrepancy with the dressing. V5 said the dressing was not changed by him on 4/1/22, 4/2/22, or 4/3/22 as the TAR indicated. V5 removed the dressing and there was a scab…

    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 · Dcited before2022-04-06 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide incontinence care in a manner to prevent infection to 1 of 3 residents (R87) reviewed for incontinence care in the sample of 35. On 4/4/22 at 9:57 AM, R87 was in bed with a strong urine odor. V6 (Certified Nursing Assistant-CNA) removed R87's incontinent pad, which was totally soiled with urine. V6 (CNA) took a disposable incontinent wipe, and wiped R87's frontal area once. Then V6 turned R87 to her side and wiped R87's buttocks. There were no further cleansing to R87's thighs and peri areas. On 4/5/22 at 1:45 PM, V3 (License Practical Nurse- LPN) said when providing incontinence care, cleanse peri areas and thighs thoroughly to prevent skin breakdown and infection. R87's facility assessment dated [DATE] show's R87 is always incontinent of urine. R87's latest care plan show-toilet use- Provide prompt peri care shift and as needed. A facility document entitled Incontinence Care Competency (undated) show, b.wash the perineum moving…

    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 · Dcited before2022-04-06 · tag F0755 — failed to provide safe pharmacy services — isolated
    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, interview, and record review the facility failed to ensure medications were dispensed according to standards of practice for 1 of 4 residents (R59) reviewed for pharmacy services in the sample of 35. The findings include: On 4/4/2022 at 9:48 AM, there was a plastic medication cup with 1 orange pill inside it sitting on R59's bed side table. R59 said the nurses bring her medications in and some of them just leave them in the room for her to take and others watch her take them. On 4/4/2022 at 10:11 AM, V9 Registered Nurse/RN said sometimes we can let residents take their own medications. I know ones I need to watch take them and others I stand, and spoon feed their medications to them. On 4/5/2022 at 8:45 AM, V8 Licensed Practical Nurse/LPN said they have no residents who have current orders to self-administer their own medications. V8 said nurses have to watch the residents take their medications. On 4/6/2022 at 8:14 AM, V2 (Director of Nursing) said nurses are not supposed to leave medications at the bedside for a resident to take, they have to stand and watch…

    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 · D2022-04-06 · tag F0761 — failed to label and store drugs safely — isolated
    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

    Based on observation, interview, and record review the facility failed to ensure medications were secured for 2 of 35 residents (R52 and R38) reviewed for medications in the sample of 35. The findings include: 1. A facility assessment done on 1/14/22 showed R52 was mentally intact. R52's Order Summary Report showed an order for an ipratropium-albuterol inhaler to be given 6 times a day as needed and an order for glycopyrrolate nebulizer to be given two times a day. On 04/04/22 at 12:01 PM, R52 had an ipratropium-albuterol inhaler and two glycopyrrolate nebulizer ampules sitting on his bedside table. R52 said the medications are kept at his bedside. On 04/06/22 at 09:39 AM, V3 (LPN) said medications are kept secured by keeping them in the locked medication cart and if medications are kept at bedside they are not secured. On 04/05/22 at 09:12 AM, V4 (Licensed Practical Nurse - LPN) said R52 has not been assessed to keep medications at bedside or to self-administer medications. R52's Order Summary Report printed on 4/5/22 at 10:49 AM showed an order to self-administer 6 AM medications…

    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 · Dcited before2022-04-06 · 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 observation, interview and record review the facility failed to wash hands and change gloves to prevent the spread of infection to 1 of 35 residents (R99) reviewed for infection control in the sample of 35. The findings include: On 04/04/22 at 10:15 AM, V6 (Certified Nursing Assistant-CNA) provided incontinence care to R99 . R99 had large amount of stool that soaked thru her incontinent pad, her bed sheets and blankets. V6 (CNA) cleaned large amount of loose stool from R99. With visibly soiled gloves on, V6 touched multiple surfaces, applied incontinent pad to R99, turned R99 side to side, changed R99's bed sheets, adjusted R99 in bed, touched her pillows, applied new covers to R99. V6 did all these tasks without washing her hands and changing her gloves. At 1:00 PM, V6 CNA said she was not sure when to change her gloves or wash her hands when providing care. On 4/5/22 at 1:45 PM, V3 (LPN) said that gloves should be removed and then staff should wash hands or sanitize after providing care to the residents. Then apply new gloves before touching anything else for infection…

    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

“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

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 →

RatingThis homeChain avg
Overall 4 of 52.9+1.1 vs chain
Health inspection 4 of 52.8+1.2 vs chain
Staffing 2 of 52.5-0.5 vs chain
Quality measures 4 of 53.3+0.7 vs chain
The other 88 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Avantara ArrowheadRapid City, SD 1 of 5Avantara Evergreen ParkEvergreen Park, IL 1 of 5Avantara MilbankMilbank, SD 1 of 5Avantara Saint CloudRapid City, SD 1 of 5Avantara WatertownWatertown, SD 1 of 5Emmetsburg Care CenterEmmetsburg, IA 1 of 5Grove Of Elmhurst, TheElmhurst, IL 1 of 5Harmony Cedar RapidsCedar Rapids, IA 1 of 5Harmony House Health Care CenterWaterloo, IA 1 of 5Harmony MarshalltownMarshalltown, IA 1 of 5Harmony WaterlooWaterloo, IA 1 of 5Harmony West Des MoinesWest Des Moines, IA 1 of 5Nexus at BerwynBerwyn, IL 1 of 5Northgate Care CenterWaukon, IA 1 of 5Park View Rehabilitation CenterSac City, IA 1 of 5Southfield Wellness CommunityWebster City, IA 1 of 5Warren Barr South LoopChicago, IL 2 of 5Avantara GrotonGroton, SD 2 of 5Avantara HuronHuron, SD 2 of 5Avantara Lincoln ParkChicago, IL 2 of 5Avantara Mountain ViewRapid City, SD 2 of 5Avantara Palos HeightsPalos Heights, IL 2 of 5Avantara PierrePierre, SD 2 of 5Avantara RedfieldRedfield, SD 2 of 5Bella Terra BloomingdaleBloomingdale, IL 2 of 5Bella Terra Morton GroveMorton Grove, IL 2 of 5Carlton At The Lake, TheChicago, IL 2 of 5Chalet Living & RehabChicago, IL 2 of 5Colonial Manor of ElmaElma, IA 2 of 5Hallmark Care CenterMount Vernon, IA 2 of 5Harmony DavenportDavenport, IA 2 of 5Harmony DubuqueDubuque, IA 2 of 5Harmony PalosPalos Heights, IL 2 of 5Harmony Utica RidgeDavenport, IA 2 of 5Heritage Care And Rehabilitation CenterMason City, IA 2 of 5Manor House Care CenterSigourney, IA 2 of 5Peterson Park Health Care CtrChicago, IL 3 of 5Avantara LibertyvilleLibertyville, IL 3 of 5Avantara NorthRapid City, SD 3 of 5Bloomfield Care CenterBloomfield, IA

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 / managerTypeRoleShareSince
DOROS GENERATION TRUST U/A/D 1/3/12Organization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF50%since 01/01/2017
GPN FAMILY TRUST U/A/D 4/28/08Organization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF50%since 01/01/2017
BUFFALO PROPERTY HOLDINGS, LLCOrganization5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 01/01/2017
LAKE FOREST BANK & TRUST COMPANY, N.A.Organization5% OR GREATER SECURITY INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 12/01/2024
SHABAT, MENACHEMIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2017
LEGACY HEALTHCARE FINANCIAL SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2017
BURAU, EMILYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/08/2025
PAPANOS, NICHOLASIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2017
RSM US LLPOrganizationADP OF THE SNFsince 01/01/2025

CMS files one row per role, so the 18 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.

6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$19.9M
Net patient revenuemost recent cost report
-8.9%
Operating marginrevenue minus expenses
$2.5M
Related-party expense11% of expenses
Who pays — share of resident-days
Medicaid 31%Medicare 12%Other / private 57%

This home reported $2.5M paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$359per resident / day
operating cost
$10,928per month
≈ monthly operating cost
$330per 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 145868. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-08-08, 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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