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Avira Health Pavilion

6131 Park Ridge Road, Loves Park, IL 61111 · For profit - Limited Liability company · 54 certified beds · (815) 633-6810 Medicare & Medicaid certified

Call the home — (815) 633-6810 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

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
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • nursing-staff turnover (63%) runs well above the national median (45%)

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) 4 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
6121 N 2nd St · (815) 633-5151 · Call to confirm hours
Pharmacy
Walgreens0.5 mi
5900 N 2nd St · (815) 282-2077 · Call to confirm hours
Grocery
868 W Riverside Blvd · (815) 282-5347 · Call to confirm hours
Park
5701 Park Ridge Rd · (815) 987-8800 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
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 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.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Short-stay residents who newly got an antipsychotic medication0.0%2.2%1.4%better
Short-stay residents given the seasonal flu vaccine98.6%63.1%79.4%better
Short-stay residents rehospitalized after admission34.1%26.1%22.6%worse
Short-stay residents with an outpatient ER visit19.7%13.9%12.0%worse

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

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

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

63.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 439 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

63.0%U.S. median 51.5%
Got home and stayed home
11.0%U.S. median 10.7%
Went back to hospital
53.7%U.S. median 56.6%
Met the expected recovery
0.98U.S. median 0.31
Therapy hours / resident / day
0.48hours / resident / day
Physical therapy
0.39hours / resident / day
Occupational therapy
0.10hours / resident / day
Speech therapy

Met the expected recovery: 53.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 162 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 0.98 therapist hours per resident per day in 2026Q1 — more than 97% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 25% 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 SNF63.0%CMS range 59.6–66.651.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.0%CMS range 9.1–13.510.7%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 discharge53.7%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge56.8%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 discharge63.0%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 identified100.0%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 worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.0%CMS range 4.8–10.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.021.02Oct 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

1.24
RN hours/ resident / day
1.32
LPN hours/ resident / day
3.08
Aide hours/ resident / day
5.63
Total nurse hours/ resident / day
1.31
RN hoursweekends
62.7%
Total nursing turnover
44.4%
RN turnover

How full it usually is: this home is certified for 54 beds and averages 25.4 residents a day — about 47% occupied, or roughly 29 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.63 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.24 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.08 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 5.09 hrs/resident/day on weekends vs 5.85 on weekdays — 13% thinner on weekends. RN hours go from 1.21 to 1.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 63% is well above 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

3
deficiencies at the latest standard inspection (2025-07-24)
6
at the previous standard inspection (2024-09-11)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

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.

24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.

  • Actual harm · G2023-08-03 · tag F0697 — failed to manage pain — isolated
    Provide 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 observation, interview and record review, the facility failed to ensure a resident's pain level was controlled. This resulted in the resident experiencing severe pain. This applies to 1 of 2 residents (R138) reviewed for pain in the sample of 17. The findings include: R138's admission Record sheet shows he was admitted on [DATE]. The same document shows his diagnoses includes right knee joint replacement surgery, depression, and anxiety. On 8/01/23 at 2:34 PM, R138 was in his room with the ice water pump attached to his right knee. R138 had periods of facial grimacing when he moved his leg. On 8/01/23 at 2:34 PM, R138 said, he just had a right knee replacement and he is in severe pain. R138 said, the only thing the nursing staff will give him is Acetaminophen. R138 rated his pain at an 8 during our interview. R138 said, he tells everyone he can, both the nurses and CNA's (Certified Nursing Assistants) that he is in pain. R138 said, he told the nursing staff he needed something stronger. On 8/02/23 at…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-17 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    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 a resident's sink in a safe, functional manner for 1 of 3 residents (R1) in the sample of 3.The findings include:On 3/17/26 at 8:50 AM, R1 was sitting up in her wheelchair. The surveyor asked R1 if she had access to warm water in her sink. R1 stated, Why don't you go check the sink? The surveyor entered R1's bathroom and the hot water knob appeared loose. When the surveyor attempted to turn on the hot water, the knob fell off the sink and onto the floor. The resident laughed and said, You see what I'm talking about. It's been broken since I got here. I can get warm water if I mess with it. It's annoying for sure. I'd think they would have fixed it by now. When I first came, I had a roommate and she said it was broken before that, but I don't know how long. R1 said she didn't recall maintenance coming in to fix it. R1 said the Certified Nursing Assistants (CNAs) knew it was broken.R1's Face Sheet dated 3/17/26 showed she 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-07-24 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to adequately store food items by not properly labeling and/or dating items; and failed to ensure the sanitizing solution was at the recommended level. This failure has the potential to affect all 29 residents currently residing in facility.Findings include:On 07/22/2025, upon entering facility, V1 (Administrator) indicated resident in-house census of 29. Facility provided a completed CMS 802 form that indicated resident census of 29.On 07/22/2025 at 10:40 AM, initiated kitchen tour with V4 (Food Service Director) with the following observations. At 10:51 AM, red sanitation bucket near the three compartment sink was tested by V4 (Food Service Director) and test strip read 150 ppm (parts per million). V4 indicated that the sanitizer level should be at 200 ppm. V4 added that staff have been using this same sanitizing solution all morning. At 11:40 AM, observed in storage refrigerator, a jar of marble glaze and minced garlic both opened and undated, and both visibly used. At 11:43 AM, observed in storage freezer an…

    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 · D2025-07-24 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents were able to operate their televisions for 2 of 2 residents (R31 & R8) reviewed for choices in the sample of 14. The findings include:1. On 7/23/25 at 8:17 AM, R31 was sitting in a wheelchair in the dining room at the table. R31's right lower extremity was elevated up on a footrest with an elastic wrap around her leg. R31 had a wound vacuum in place and a device to provide cold therapy to her knee. R31 stated she was admitted to the facility a few days ago and her television (TV) did not work; it would not turn on with her remote. R31 stated someone came in, got up on a ladder, and pushed the button on the tv to turn it on. She stated after that the TV remained on; it couldn't be turned off, changed, or the volume controlled. R31 stated told staff about it. She said she hasn't been able to sleep because the TV stayed on. At 8:20 AM the surveyor went to the resident's room with her permission. There were two remote controls…

    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 before2025-07-24 · 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 ensure infection control was maintained and prevent any cross contamination during wound care for 1 of 1 residents reviewed for wounds in the sample of 14. Findings include:On 7/23/25 at 7:56 AM, V10 Licensed Practical Nurse (LPN) went into R38's room to provide wound care to his right elbow and right knee. V10 put gloves on, removed normal saline and triple antibiotic ointment from the treatment cart and placed it on a small disposable tray next to some gauze. V10 changed her gloves, took the tray into the resident's room, and sat it on the over the bed tray table next to R38. V10 opened a small pink saline tube and squirted it onto the gauze and then cleaned off scabs and abrasion to his right elbow. V10 used the second pink tube of saline and squirted it over his right elbow. V2 Director of Nursing (DON) walked into the room. V10 put antibiotic ointment on her gloved finger and applied it to the scabs and abrasion on R38's right elbow. V10 removed her gloves, left the room to get more saline tubes. V2 went…

    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 · E2025-06-26 · tag F0806 — failed to honor food preferences — pattern
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to accommodate residents' food preferences and choices for 4 of 6 residents (R2, R3, R5, R6) reviewed for residents' food preferences and choices in the sample of 6. The findings include: The facility's daily menus dated 6/11/25-6/24/25 showed primarily cold foods and/or room-temp foods, such as cold cereal, canned fruit, deli meat sandwiches, potato chips, salads, ice cream, and pudding, were listed as the available food items on the menus. A limited selection of hot foods were listed as menu choices which included scrambled eggs, oatmeal, hamburgers, mashed potatoes, and grilled cheese sandwiches. The menus showed, Due to complication in the kitchen we will be in emergency mode until further notice we do apologize for the inconvenience. On 6/26/25 at 8:59 AM, V3 (Registered Dietician) stated on 6/11/25, the facility began serving primarily cold foods, including sandwiches, salads, and fruit to residents at meals because the dumbwaiter (elevator that carries food from the kitchen to the facility's dining room) had broken. 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-26 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    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 breakfast meal was a smooth pureed consistency for 1 of 1 residents (R1) reviewed for pureed diets in the sample of 6. The findings include: R1's Swallow Screening Note dated 5/13/25 showed R1 had diagnoses of dementia and an unspecified muscle disorder. The note showed during the swallow evaluation, R1 remained inconsistent in his ability to swallow and adequately clear (food) bolus, resulting in expectorating (coughing up) bites . It is recommended that the patient's diet be downgraded to a pureed consistency for safety and improved nutritional intake. R1's Dietary Note date 5/23/25 showed R1 was evaluated by V3 Registered Dietician for weight loss. The note showed R1's diet had been downgraded to a pureed consistency for safety. On 6/26/25 at 8:00 AM, V5 [NAME] plated R1's breakfast tray. At 8:01 AM, R1 was served breakfast which included scrambled eggs, pureed sausage, applesauce, and oatmeal. Clumps of eggs were noted in the scrambled eggs. Clumps of oatmeal were noted in the oatmeal. R1 picked…

    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 · F2025-04-03 · tag F0680 — widespread
    Ensure the activities program is directed by a qualified professional.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, interview, and record review the facility failed to have a full time Activity Director. This applies to all 32 residents in the facility. The findings include: The Facility census sheet dated 03/30/2025 at 11:59PM, shows, 32 residents in the facility. On 03/31/2025 at 11:25AM, V1 Administrator said, We do not have an Activity Director. On 03/31/2025 at 2:00PM, V2 DON-Director of Nursing said, We do not have an activity calendar for March (2025). The facility's Activity Programs policy revised June 2018 shows, Activity programs are designed to meet the interests of and support the physical, mental, and psychosocial wellbeing of each resident. Activities are scheduled 7 (seven) days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the programs. Scheduled activities are posted on the resident bulletin board. Activity schedules are also provided individually to residents who cannot access the bulletin board.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-03 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    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 an activity program to meet the individual interests of the residents for 5 or 5 residents (R4, R5,R6,R8,R9) reviewed for activities in the sample of 9. The findings include: On 03/31/2025 at 9:09AM, R4 way lying in bed and R5 was sitting in a reclining chair. R4 and R5 did not have an activity calendar in their room. At 9:18AM, R6 was in an isolation room, alone, sitting in a reclining chair. R6 did not have an activity calendar in her room. At 9:40AM, R8 was lying in bed. R8 did not have an activity calendar in her room. At 9:55AM, R9 was sitting in a wheelchair in her room. R9 did not have an activity calendar in her room. On 03/31/2025 at 9:09AM, R4 said, There are not too many activities except for therapy. On 03/31/2025 at 9:13AM, R5 said, There are no activities. There is nothing to do on the weekends, we do not have therapy on Saturday or Sunday. On 03/31/2025 at 9:18AM, R6 said, I was here last year, they were going to start BINGO. For this stay I have been on isolation for most of the 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-09 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure 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 interview and record review the facility failed to ensure two residents (R1, R2) received their evening medications in a timely manner. This applies to 2 of 10 residents (R1, R2) reviewed for nursing care in the sample of 10. The findings include: On 1/9/25 at 12:50 PM, R2 said on 1/4/25, R2 and R1 (R1's roommate) requested their evening medications from V7 multiple times and V7 argued with R1 and R2 insisting that V7 administered their evening medications. R1 and R2 both stated V7 did not appear to be under the influence during this discussion. R1's January Medication Administration Record (MAR) shows that all R1's evening medications for 1/4/25 were signed as given by V2 (Director of Nursing). R2's January MAR shows that all R2's evening medications for 1/4/25 were signed as given by V2. On 1/9/25 at 10:54 AM, V2 said on 1/4/25, V7 (LPN) sent V2 a text message at approximately 10:50 PM that read, I'm so k of these delusional ass home telling me I'm not giving them meds . I can drop me all day long they I wild b clean. (sic) V2 awoke at approximately 11:20 PM on 1/4/25,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-09-11 · tag F0908 — failed to keep essential equipment working — widespread
    Keep all essential equipment working 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 the walk in freezer was repaired and in safe working condition. This failure has the potential to affect all 24 residents residing in the facility. The findings include: The CMS-671 form completed by the facility on 9/9/24, shows there are 24 residents residing in the facility. During the kitchen tour on 9/9/24 at 9:10 AM, thick frost was noted on the packages of food in the walk in freezer and frozen water was pooled on a box of cookies and a box of diced turkey on the shelf below the fans. A large puddle of water was on the floor between the walk in freezer and the walk in cooler coming from water dripping from the connecting door. V5, Dietary Manager, said the freezer was down and they had a repair company out to fix it about a month ago. V5 said they are waiting on a part to fix the freezer. On 9/9/24 at 12:46 PM, V20, Freezer repair company representative, said they provided an estimate to fix the facility's freezer on 7/30/24. V20 said they have not been waiting for parts to fix the facility's…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · Dcited before2024-09-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to obtain treatment orders for a resident with a stage 3 pressure injury. This applies to 1 of 2 residents (R5) reviewed for pressure injury in the sample of 12. The findings include: R5's face sheet shows she was admitted to the facility on [DATE] with diagnoses including septic shock and a stage 3 pressure injury to her left heel and sacrum. Hospital discharge records for R5 show prior to admission to the facility she was in a local community hospital with a diagnosis of septic shock due to a left heel ulcer which had been debrided and antibiotic therapy provided while she was at the hospital. An initial nursing admission assessment for R5 dated 8/21/24 and not signed, shows she has a left heel ulcer measuring 1.6 centimeters (cm.) x 1.8 cm. The same assessment shows she has 3 open areas to her sacrum/coccyx and right and left buttocks measuring: 2.0 x1.0 cm. and 1.5 cm x 2.0 cm. and 1.0 cm. x 1.0 cm. R5's current Physician Order Summary (POS) 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-11 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure dietary supplements were provided for 2 of 5 residents (R28, R5) reviewed for weight loss in the sample of 12. The findings include: 1.) R28's face sheet shows he was admitted to the facility on [DATE] with diagnoses including protein-calorie malnutrition and muscle weakness. R28's active care plan shows he has malnourishment and will be consulted by the dietician. R28's Weight Summary shows his weight was 110.2 on 8/27/24 and was 101.4 on 9/6/24 which is a 7.99% and 8.8 pound (lb.) significant weight loss in 10 days. R28's Nutrition note completed on 9/6/24 by V4 (Dietician) shows he has sustained a significant weight loss and Magic Cup a dietary supplement had been ordered to be given with lunch. R28 declined any additional supplements. R28's active Physician Order Summary and meal ticket both show he should receive magic cup with lunch effective 9/1/24. On 9/9/24 the noon meal service was observed and R28 was in the dining room…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-11 · 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 interview and record review the facility failed to ensure there was no delay in obtaining a medication from the pharmacy and failed to obtain a medication from the pharmacy for 2 of 5 residents (R235 and R11) reviewed for pharmacy services in the sample of 12. The findings include: 1. R235's Face Sheet showed R235 had a primary diagnosis of polyneuropathy (a nerve disease that affects many nerves). On 09/09/24 at 12:05 PM, R235 said he had neuropathy (nerve pain) in his hands and feet. R235 described the pain as if his hands and feet were on fire. R235 said there was a delay in starting medication for the nerve pain. R235 said it took the facility over a day to get the medication. R235 was not sure why there was a delay. R235 said the facility did provide other interventions while waiting for the pain medication to treat the neuropathy. R235's Progress Notes dated 9/4/24 entered by V10 (Nurse Practitioner) showed R235 reported he had neuropathy and was agreeable to try pregabalin (medication to treat the nerve pain). R235's Progress Note dated 9/4/24 at 12:49 PM showed a…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-11 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review the facility failed to ensure PRN (as needed) psychotropic medication had a stop date not greater than 14 days for 1 of 5 residents (R11) reviewed for psychotropic medications in the sample of 12. The findings include: R11's Physician Order Summary and Medication Administration Record both show an active order prescribed by V11 (Nurse Practitioner) on 9/5/24 for Ativan 0.5 MG (milligrams) every 12 hours as needed for anxiety with no stop date. On 9/10/24 at 2:25 PM, V2 (Director of Nursing) said PRN orders for psychotropic medications including Ativan should have a stop date of 14 days. The facility provided Time Limited Orders policy effective 10/25/24 shows PRN Anxiolytics (Ativan) should have a stop date of 14 days.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-11 · 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 ensure staff wore the required personal protective equipment for a resident on enhanced barrier precautions for 1 of 12 residents (R15) reviewed for infection control in the sample of 12. The findings include: R15's Clinical Physician Orders showed R15 had an order for enhanced barrier precautions because R15 had an indwelling urinary catheter. On 09/09/25 at 9:20 AM, on the outside of R15's room was a sign indicating R15 was on enhanced barrier precautions. The sign indicated staff were to wear gloves and gown for high-contact resident care activities. High-contact activities included transferring and care of a medical device such as a urinary catheter. On 09/09/24 at 09:29 AM, R15 was in his room sitting in a wheelchair. R15's indwelling urinary catheter drainage bag was hanging on the wheelchair. V14 (Physical Therapist Assistant) was in the room. V14 moved R15's indwelling urinary catheter drainage bag from the wheelchair to a walker. V14 did not have on gloves or a gown. V14 assisted R15 to stand 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-06 · tag F0623 — isolated
    Provide 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 — the official record, unedited, may be distressing

    Based on interview and record review, the facility failed to notify a resident's family member after the resident experienced a fall. This applies to 1 of 5 (R3) residents reviewed for falls in the sample of 6. The findings include: R3's Fall Investigation report dated 2/2/24, completed by V2 (Director of Nursing), shows R3 sustained a witnessed fall in the dining room on 2/2/24 at 8:40 AM. On 2/6/24 at 1:05 PM, V7 (R3's Family Member) said the facility did not let her know of R3's fall on 2/2/24. V7 said she attended R3's care plan meeting on 2/2/24 with members from the facility and was never informed about R3's fall that occurred earlier that morning. On 2/6/24 at 1:25 PM, V2 said she was the witness of R3's fall and completed R3's fall report. V2 said she attempted to call V7, but V7 did not answer and V2 could not leave a message. V2 intended to call V7 back and never did. V2 said that notifying the resident's family member should be done immediately after the resident has been assessed and the physician has been notified and given orders.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-09 · 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

    Based on interview and record review the facility failed to assess a shearing/pressure injury for 1 of 3 residents (R1) reviewed for pressure injury in the sample of 3. The findings include: R1's progress note dated 4/18/23 showed R1 had a shearing wound to the back of his right thigh, testicles, and buttocks. The note indicated the skin was unopened. The note did not include wound measurements. R1's Nurse Practitioner's progress note dated 4/18/23 indicated staff found a bed sore on R1's coccyx. On 8/9/23 at 1:38 PM, V2 (Director of Nursing) said a wound assessment with measurements should be done when a skin issue is found. V2 said wound assessments are done to track the progress of the wound. On 8/9/23 at 2:34 PM, V2 said there were no documented skin assessments for R1's shearing wound. On 8/9/23 at 3:39 PM, V1 (Administrator) said the facility was lacking a wound assessment of R1's shearing wound. The facility's Skin Breakdown - Clinical Protocol policy dated April 2018 showed, .nurse shall describe and document/report the following: a. Full assessment of pressure sore…

    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 · Fcited before2023-08-03 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to ensure droplet precautions were maintained for residents positive with covid-19 by not keeping doors shut on rooms that were safe to have them shut and ensuring staff wore eye protection when entering a covid-19 positive residents' room. This has the potential to affect all the residents in the facility. The findings include: The facility's CMS (Centers for Medicare & Medicaid Services) form 672 Resident Census and Condition of Residents dated August 2, 2023, showed 29 residents reside in the facility. 1. On 8/1/23 at 9:50 AM, R12 was sitting up on the side of his bed with his tray table in front of him. R12 had a cup of medication on his tray table next to his untouched breakfast. V7 RN (Registered Nurse) was out in the hall and stated the door shouldn't be left open because he is on isolation for covid. V7 stated she left R12's door open to make sure R12 took his pills. V7 stated if she waited for R12 to take his medications she wouldn't get her medications passed. V7 then dispensed medications into a cup 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-08-03 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    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 change a resident's (R14) PICC line dressing as scheduled or as needed and failed to ensure a resident's PICC line end cap was changed weekly. The facility failed to ensure blood glucose monitoring was completed before meals and before residents (R24 & R17) started eating. The facility failed to ensure daily weights were done for residents (R4, R1, R17, R137 & R132). This applies to 7 of 7 residents (R14, R24, R17, R4, R1, R137, & R132) reviewed for quality of care in the sample of 17. The findings include: 1. On 8/1/23 at 11:05 AM R14 was sitting in his wheelchair in his room with Vancomycin (intravenous antibiotic) alarming on the pump that stated, air in line. The IV (intravenous) tubing for the antibiotic was attached to a PICC (Peripherally inserted central catheter) in his right upper arm. The dressing on R14's PICC line was loose and coming off. On 8/1/23 at 11:26 AM, V7 RN (Registered Nurse) went into R14's room at the request 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-03 · 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 ensure a residents safety when the brakes on her wheelchair did not engage completely putting her at risk for falling for 1 of 2 residents (R87) reviewed for safety and supervision in the sample of 17. The findings include: On 8/1/23 at 9:33 AM, V6 CNA (Certified Nursing Assistant) went into R87's room to assist her to the bathroom. V6 asked if R87 wanted to use her walker or wheelchair. R87 stated the brakes on her wheelchair were not working right and don't keep the wheels on the chair locked. V6 went over to R87's brake on her wheelchair and engaged the brakes. R87's wheelchair continued to move. V6 stated the brakes were loose. R87 stated she told someone about the brakes on her wheelchair, the person wrote the information down, but nothing has been done about it. On 8/1/23 at 9:36 AM, the surveyor checked the brakes on R87's wheelchair and the left brake did not stop the left wheel from moving when the brake was engaged. On 8/1/23 at 9:46 AM, V6 CNA (Certified Nursing Assistant) stated R87's chair 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-03 · 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 provide catheter care in a manner to prevent infection for 1 of 2 residents (R182) reviewed for catheters in the sample of 17. The findings include: R182's admission Record, printed by the facility on 8/3/23, showed he had diagnoses including retention of urine, profound intellectual disabilities, and benign prostatic hyperplasia (an enlarged prostate that can cause symptoms such as blocking the flow of urine out of the bladder). R182's Order Summary Report, printed by the facility on 8/3/23, showed an order for a Foley catheter size 16 fr (French)/10 ml (milliliter) balloon. R182's Order Summary Report (current) also showed orders to provide catheter care every shift and as needed. R182's care plan initiated on 7/26/23 showed he has a self-care deficit/impaired physical mobility/activities of daily living deficit related to weakness. R182's care plan initiated on 7/26/23 shows R182 is at risk for infection related to an indwelling catheter. One of the interventions listed on the care plan was Wash hands…

    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 · D2023-08-03 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure an Licensed Practical Nurse did not provide IV (intravenous) care for residents, unless they were IV certified. This applies to 1 of 1 resident (R137) reviewed for competent nurse staffing in the sample of 17. The findings include: On 8/02/23 at 8:26 AM, V13 (Licensed Practical Nurse-LPN) was in R137's room. V13 informed R137 that she needed to flush his IV line. V13 was observed flushing the PICC line (a long catheter that is inserted into a vein in the arm, leg or neck. The tip of the catheter is positioned in a large vein that carries blood into the heart) in R137's left arm. At 8:48 AM, V13 went back into R137's room because one of the Certified Nursing Assistants informed her that R137's IV machine was beeping. Upon entering the room, R137's IV machine was not beeping. An antibiotic (Vancomycin) was infusing into R137's left arm through the PICC line. On 8/2/23 at 4:10 PM, V1 (Administrator) said an LPN must be IV certified from the facility pharmacy or another reputable pharmacy in order to do…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-03 · 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 medications were not left at the resident's bedside for 3 of 3 residents (R12, R81, & R137) reviewed for medications in the sample of 17. The findings include: 1. On 8/1/23 at 9:50 AM, R12 was sitting up on the side of his bed with his tray table in front of him. R12 had a cup of medication on his tray table next to his untouched breakfast. V7 RN (Registered Nurse) was out in the hall and stated they are not supposed to leave medications at the bedside. V7 stated she left R12's door open to make sure R12 took his pills. V7 stated if she waited for R12 to take his medications she wouldn't get her medications passed. V7 then dispensed medications into a cup and went into another resident's room and shut the door. The Face Sheet dated 8/2/23 for R12 showed medical diagnoses including dysphagia, pneumonia, acute respiratory failure with hypoxia, sepsis, vomiting, unspecified intestinal obstruction, opioid dependence, hypothyroidism,…

    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

“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.

Who owns this facility

Owner / managerTypeRoleShareSince
ADVANCED MANAGEMENT COMPANYOrganizationDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2021
PALAZZO, JAMESIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF99%since 06/15/2005
DALE, JAMESIndividualINDIRECT OWNERSHIP INTEREST; CORPORATE OFFICERsince 01/01/2022
DISANTI, STEVENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/06/2017
WOODS, RENEEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/13/2023

CMS files one row per role, so the 13 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

Net patient revenuemost recent cost report
Operating marginrevenue minus expenses
$673K
Related-party expense10% of expenses
Who pays — share of resident-days
Medicaid 0%Medicare 57%Other / private 43%

This home reported $673K paid to related parties — landlords or management companies under common ownership — equal to about 10% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

$624per resident / day
operating cost
$18,968per month
≈ monthly operating cost
not reportedthis home filed no revenue line
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 146069. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-24, 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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