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St Patrick's Residence

1400 Brookdale Road, Naperville, IL 60563 · Non profit - Corporation · 209 certified beds · (630) 416-6565 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Flagged for abuse1 immediate-jeopardy citation$110,030 in federal fines
Insights

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

In its favor
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (29% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • CMS has flagged it for abuse
  • it has abuse, neglect, or exploitation citations (F0600, F0610) — most recent Apr 2026
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $110,030 in federal fines (most recent 2026-03-26)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

Worth a closer look. This home's staffing rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Urgent care / clinic
636 Raymond Dr · (630) 355-5302 · Call to confirm hours
Pharmacy
612 Raymond Dr · (630) 428-9171 · Call to confirm hours
Grocery
1250 W Ogden Ave · (630) 445-8927 · Call to confirm hours
Park
1520 Brookdale Rd · (630) 848-5000 · 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 3 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 1 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 fell from 4 to 2 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 rating2★
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 increased7.1%13.4%15.4%better
Long-stay residents who lose too much weight5.3%6.3%5.4%typical
Long-stay residents with a catheter left in their bladder0.1%0.9%0.9%better
Long-stay residents with a urinary tract infection0.9%1.5%2.0%better
Long-stay residents with depressive symptoms2.2%54.2%6.5%better 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 injury2.0%3.1%3.3%better
Long-stay residents whose ability to walk worsened10.4%14.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication14.3%18.3%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%91.8%95.3%typical
Long-stay residents with pressure ulcers1.3%4.8%4.7%better
Long-stay residents with worsening bladder/bowel control23.1%20.6%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table15.5%21.7%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.5%2.2%1.4%better
Short-stay residents given the seasonal flu vaccine93.8%63.1%79.4%better
Short-stay residents rehospitalized after admission26.9%26.1%22.6%worse
Short-stay residents with an outpatient ER visit14.5%13.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.562.021.67worse
Long-stay outpatient ER visits per 1,000 resident days1.632.221.80typical

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.

45.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 228 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

45.9%U.S. median 51.5%
Got home and stayed home
8.6%U.S. median 10.7%
Went back to hospital
32.1%U.S. median 56.6%
Met the expected recovery
0.16U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 32.1% 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 137 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 0.16 therapist hours per resident per day in 2026Q1 — more than 14% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 30% 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 SNF45.9%CMS range 39.1–51.351.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.6%CMS range 6.6–12.210.7%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 discharge32.1%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 discharge28.5%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 discharge25.6%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.0%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 hospitalization7.1%CMS range 4.1–10.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.041.02Oct 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

1.01
RN hours/ resident / day
0.53
LPN hours/ resident / day
2.52
Aide hours/ resident / day
4.06
Total nurse hours/ resident / day
0.81
RN hoursweekends
28.9%
Total nursing turnover
14.3%
RN turnover

How full it usually is: this home is certified for 209 beds and averages 166.0 residents a day — about 79% occupied, or roughly 43 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.06 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.01 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.52 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 3.75 hrs/resident/day on weekends vs 4.18 on weekdays — 10% thinner on weekends. RN hours go from 1.09 to 0.81 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 29% is below the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

6
deficiencies at the latest standard inspection (2025-01-16)
8
at the previous standard inspection (2024-02-23)

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.

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

  • Immediate jeopardy · J2026-04-13 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct a thorough and impartial investigation of resident abuse by a staff member. The facility also failed to maintain documentation from the witnesses of the abuse. R1 experienced pain and was crying following the incident. The alleged perpetrator was allowed to return to work another two shifts with R1. A reasonable person would experience fear and anxiety having the alleged perpetrator provide care for a dependent resident with a history suffering from abuse. This applies to 1 of 3 residents (R1) reviewed for abuse in a sample of 3.The findings include: The facility failed to conduct a thorough and impartial abuse investigation. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] at 5:40 PM when CNA (Certified Nursing Assistant) students reported to V9 (Wound Nurse/Nurse Supervisor) that they witnessed V8 (CNA) abuse R1. V9 then conducted witness interviews in a coercive manner, failed to substantiate the abuse…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2026-05-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a resident did not fall out of bed after being turned during incontinence care. This failure resulted in the resident slipping off the bed and experiencing bilateral distal femur fractures requiring bilateral femoral retrograde rodding. This applies to 1 of 3 residents (R1) reviewed for falls in a sample of 3. Findings Include:Review of R1's care plan shows R1's diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting her left side, osteoarthritis, and dementia with impaired thought processes. R1 was at increased risk for falls related to her weakness, hemiplegia, poor balance/coordination, and medications. R1 utilized a pressure-relieving mattress on her bed, had altered functional range of motion of her left side, required a mechanical lift and two staff for transfers, used 1/4 side rails to enable bed mobility, and prior to her fall required the maximal assistance of one staff but may need two staff at times for bed mobility. MDS (Minimum Data Set), dated 4/14/26, shows R1's cognitive…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2026-04-13 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect a resident from physical and mental abuse from staff. These failures caused R1 to sob and experience pain following the episode of witnessed abuse. This applies to 1 (R1) of 3 residents reviewed for abuse in a sample of 3. A reasonable person would experience fear and anxiety of the alleged perpetrator to provide care for a dependent resident with a history of suffering from abuse and has experienced significant trauma during their lifetime as stated in the care plan. The findings include: R1's Face sheet dated 4/10/26, shows R1's diagnoses included metabolic encephalopathy, dementia with psychotic disturbance, adult failure to thrive, major depression disorder, pain in left and right knee and low back pain, cervicalgia, muscle weakness, noncompliance with other medical treatment, psychosis not due to a substance, anxiety, hemiplegia, and legal blindness. The face sheet shows R1 was admitted to the facility on [DATE] and expired at the facility…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-13 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to notify the local law enforcement agency regarding allegations of resident abuse per the facility policy. This applies to 2 (R1 and R2) of 3 residents reviewed for abuse allegations in the sample of 3.The findings include: 1.Initial abuse report dated March 25, 2026, and final report dated March 27, 2026, shows an allegation of physical abuse was reported to the facility regarding R1. On 4/6/26 at 3:09 PM, V14 (Certified Nursing Assistant/CNA Student) stated she and V5 (CNA Student) witnessed V8 (CNA) pushing R1 on her left side while lying in bed and using a lot of unnecessary force - it looked like she was hurting her. V14 stated R1 was telling V8 to stop, and she was being hurt and V8 was pressing very hard on R1's shoulder while leaning over her and putting her weight into R1. V14 stated she and V7 (CNA Student) were then sent into R1's room to feed R1. V14 stated R1 began sobbing and stated V8 hurt her. V14 stated R1 attempted to show V14 and V7 her knee where it hurt and R1 grabbed V14's shoulder and told V14 and V7…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-01-16 · tag F0847 — widespread
    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility's Arbitration Agreement failed to have the required language in the Arbitration Agreement Contract. This applies to all 170 residents residing in the facility. The findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid dated January 13, 2025, by V1 (Administrator) showed the facility census was 170 residents. The facility provided their Facility's admission Contract Between Resident and [Facility] (Short-Term Rehabilitation Care and Long-Term Care Services) contract. On pages 17-18, the contract explained the arbitration agreement, but failed to let the resident and /or the resident representative know that signing this contract was not a condition of their admission to this facility or that after signing the agreement, that they had 30 days to rescind the agreement. On January 13, 2025 at 9:32 AM, during entrance conference, V1 (Administrator) said the arbitration agreement is part of the admission packet. V1 said she has not had any newly admitted resident or their representative refuse to…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-01-16 · tag F0848 — widespread
    Provide a neutral and fair arbitration process and agree to arbitrator and venue.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record review the facility's Arbitration Agreement failed to have a process for selecting a neutral arbitrator. The facility also failed to provide a selection of venues that is suitable for residents or their representatives. This applies to all 170 residents residing the facility. The findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid dated January 13, 2025, by V1 (Administrator) showed the facility census was 170 residents. On January 14, 2025, at 3:03 PM, the facility's admission Packet which included the facility's Arbitration Agreement showed under General (q) Alternative Dispute Resolution: (i) Arbitration Agreement: .The Parties will cooperate with one another in selecting an arbitrator from the arbitration company panel of arbitrators and pursue diligently the arbitration . (Name of Association) Dispute Resolution Service will Administer the arbitration . If (Name of Association) or it's successor is not available to administer the arbitration, then the Facility will select another arbitration service to…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-01-16 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their Water Management Plan for Legionella. The facility also failed to perform hand hygiene during provisions of care. This applies to all 170 residents residing in the facility. The findings include: 1. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated January 13, 2025, by V1 (Administrator) showed the facility census was 170 residents. The facility's Water Management Plan dated September 17, 2024, showed Overview: Scope: The Water Management Plan (WMP) outlines procedures for minimizing the risk of Legionnaires' disease for persons at [the facility] site. The water systems on the site are described in tables and flow diagrams; the systems requiring control measures are noted in the Hazard Analysis . Objective: The objective of the WMP is to minimize the risk of Legionnaires' disease by managing certain building water systems for the control of Legionella bacteria. Organization: The WMP will be overseen by 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-16 · 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 assess, identify, and document a resident's skin lesion. The facility also failed to follow physician orders to consult a dermatologist for skin lesions. This applies to 1 of 4 residents (R18), reviewed for skin conditions in the sample of 34. The findings include: R18's face sheet showed her to be a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that include Vascular Dementia with mild anxiety, Chronic Diastolic Heart Failure, Chronic Kidney Disease, Personal history of Cerebral infarction, and Long Term Use of Anticoagulants. On January 13, 2025 at 10:21 AM, R18 was observed with a red lesion on the top of her nose and forehead. On January 14, 2025 at 2:27 PM, R18 was in the dining room and the red lesions to her nose and forehead were still present. V19 (Registered Nurse/RN) stated the lesions to R18 nose and forehead were skin cancer. V19 stated there are no treatments for the lesions. V19 stated they 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 · D2025-01-16 · 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 interview and record review, the facility failed to follow their policy to notify the physician of a resident's significant weight loss and to consult the dietitian to evaluate a resident with significant weight loss. This applies to 1 of 5 residents (R98) reviewed for nutrition in the sample of 34. The findings include: The EMR (Electronic Medical Record) showed R98 was admitted to the facility on [DATE], with multiple diagnoses including chronic kidney disease, congestive heart failure, dementia, and major depressive disorder. R98's Weights and Vitals Summary dated January 16, 2025, showed on July 13, 2024, R98 weighed 158 pounds and on January 13, 2025, R98 weighed 127.7 pounds resulting in a 19.18 % (percent) weight loss in six months. The documentation continued to show on October 1, 2024, R98 weighed 138.6 pounds and on November 2, 2024, R98 weighed 128.2 pounds resulting in a 7.5% weight loss in one month. As of January 15, 2025, at 10:00 AM, the facility does not have documentation to show R98…

    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 · D2025-01-16 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow physician orders for laboratory tests for a resident receiving intravenous hydration. This applies to 1 of 1 resident (R149) reviewed for laboratory services in the sample of 34. The findings include: The EMR (Electronic Medical Record) showed R149 was admitted to the facility on [DATE], with multiple diagnoses including hyperosmolality (fluid and electrolyte imbalance disorder) and hypernatremia (elevated sodium levels), Alzheimer's disease, dementia, and chronic kidney disease. On January 13, 2025, at 10:50 AM, R149 was sitting in her wheelchair. R149 had intravenous fluids infusing. R149's Order Summary Report dated January 15, 2025, showed an order dated January 12, 2025, for laboratory tests every Monday. The report continued to show an order dated January 12, 2025, Sodium Chloride Intravenous Solution 0.45% (percent), use 1000 mL (milliliters) intravenously one time a day every Monday for IVF (Intravenous Fluids), HANG AFTER MORNING LABS…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-02-23 · 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 properly label, date, and store food items and maintain a clean kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 2/20/24 documents that the total census was 162 residents. On 2/22/24 at 12:24 PM, V18 (Diet Office Assistant) said there is only 1 NPO (Nothing by Mouth) resident, and the other 161 residents eat from the facility kitchen. On 2/20/24 from 9:14 AM through 10:21 AM, the facility kitchen was toured in the presence of V3 (Director of Food and Nutrition), and the following was found: In the Cook's refrigerator: 1. A small bin of pureed ham with expiration date of 2/15. 2. A small bin of ground ham with expiration date of 1/31. 3. An unlabeled and undated opened package of what V3 said was baloney. 4. A 4 Quart bin of processed ham dated opened on 2/18 and expiration on 2/29. V3 said…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-23 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure residents dependent upon staff for ADLs (Activities of Daily Living) received nail grooming for 4 of 38 residents (R18, R101, R139, & R146) reviewed for ADLs in a sample of 38. The findings include: 1. On 02/20/24 at 11:05 AM, R18 was observed with long jagged nails, with brown substances under the nails. R18 said that she didn't like them that way and wanted them cut and filed. R18 has diagnoses including, cerebral atherosclerosis, and polyarthritis osteoporosis. R18's 11/5/24 Care plan showed an ADL self-care performance deficit related to Activity Intolerance, Dementia, Impaired balance, Limited Mobility. She was admitted to hospice services and the goal is comfort with interventions including, check nail length and trim and clean on bath day and as necessary. R18's 12/28/23 Minimum Data Set (MDS) showed that R18 cognition is severely impaired, and in Section GG I. Personal hygiene R18 needs substantial/maximal assistance. 2. On 02/20/24 at 10:49 AM, R101 was observed with her fingernails long,…

    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 before2024-02-23 · 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

    Based on observation, interview, and record review, the facility failed to maintain infection control while entering isolation, while feeding residents, and during incontinent care. This applies to 10 of 10 residents (R1, R9, R59, R60, R76, R77, R89, R98, R104 and R109) reviewed for infection control in a sample of 38. The findings include: 1. On 2/22/24 at 10:39 AM, V6 (Social Services) was observed entering R59's room without gown and gloves. At 10:41 AM, V6 came out of R59's room. V6 said she went to issue R59 a notice of discharge. V6 only had on her N95 mask and goggles on when she entered the room. V6 said thought that all the PPE (Personal Protective Equipment) she was on was sufficient, she did not look at the isolation sign on the door. There was a sign for Contact Precautions and Droplet Precautions on the door. For the contact precaution sign, providers and staff must put on gloves and gown before entering the room, discard gloves and gown before exiting the room. R59's lab result of 2/14/24 showed that R59 tested positive for RSV (Respiratory Syncytial Virus). R59's EMR…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · D2024-02-23 · 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

    Based on observation, interview, and record review, the facility failed to provide a dignified dining experience to residents and failed to provide privacy during incontinence care. This applies to 3 of 3 residents (R9, R60, R77) reviewed for dignity in a sample of 38. The findings include: 1. On 02/20/24 at 11:50 AM, V13 (Certified Nursing Assistant/CNA) started to provide incontinence care for R9 when the state surveyor came into the room. V13 then stopped providing care and said, I need to get more help. She then left the room with the resident with her gown up over her chest, the sheet and blanket pulled down to the end of the bed, and the curtain and door open. R9 was left exposed to anyone walking in the hallway. At 11:54 AM, V13 return to the room with V14 (CNA). On 02/21/24 at 10:31 AM, R9 said it bothered her to be left exposed with the door and curtain open. I'm not for their show and tell. R9 said it has happened before and that staff should be more in tuned to what the patient is feeling and how leaving the door open makes them feel. On 02/20/24 at 12:03 PM, V13 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 · D2024-02-23 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide an appropriate size wheelchair for a resident. This applies to 1 of 1 resident (R70) reviewed for wheelchairs in a sample of 38. The findings include: On 2/20/24 at 10:42 AM, during initial tour of the facility, surveyor asked R70 if she had any concerns. R70 stated, Yes, I do have a concern. I'm missing my wheelchair. This wheelchair here is not mine. Mine had my name on it and it was bigger. It was black. This wheelchair is too small. It's too low to the ground and too tight across my hips. I don't remember when it was exactly missing. I've told everyone that has come to my room that it's missing. I've told them the new wheelchair is uncomfortable, but no one is doing anything about it. I need my old one back. I can't use this one because it's just not the right size and it's uncomfortable. On 2/20/24 at 11:00 AM, surveyor tried to locate R70's Certified Nursing Assistant/CNA. V23 (CNA) stated R70's CNA was on her break. Surveyor asked V23 if R70 ever complained to her that her wheelchair 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-23 · 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 — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. R107's face-sheet showed, R107 was admitted to the facility on [DATE] and her diagnoses included inflammation of the gallbladder and laparoscopic cholecystectomy. R107's MDS (Minimum Data Set) dated 4/14/23 showed, R107 is cognitively intact (BIMS-Brief Interview of Mental Status-score of 15) and required extensive assist for ADLs (activities of daily living). R107's progress notes dated 4/17/23 at 7:51 PM showed R107 was sent to the hospital for investigation and confirmation of fracture of the right hip. Records lacked documentation to show that the notice of transfer or discharge was given in writing to the resident or her representative upon transfer or discharge or as soon as practicable. Records lacked documentation to show, the facility sent a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman within 30 days. On 2/22/24 at 12:15 PM, V19 (Director of Mission Integration) stated, notice of transfer or discharge was not given in writing, to the resident or her…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-23 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide in writing to residents and their families/POA (Power of Attorney) regarding bed hold and return at the time of discharge to the hospital. This applies to 3 of 3 residents (R41, R107, R208) reviewed for discharge in a sample of 38. The findings include: 1. On 2/22/24 at 12:02 PM, V1 (Administrator) stated R41 was not given a bed hold notice at the time of discharge to the hospital. She stated that during the time of admission, the residents are given a contract regarding bed holds, but not at discharge. R41's face sheet shows an admission date of 10/5/23 to the facility. R41's progress notes document the following: On 12/23/23 at 11:40 AM, (R41) had a scant amount of pink tinged sputum. On 12/23/23 at 3:48 PM, Spoke with nurse practitioner. Verbal order read back to send out (R41) to the hospital ER (Emergency Room) Spoke with (R41's) POA. He is aware of the situation and transfer to the hospital. Left facility via 911 at 3:43 PM. On 12/23/23…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-23 · 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 provide interventions and supervision to 2 of 2 residents (R9, R29) who were at risk for falls in a sample of 38. The findings include: 1. On 02/20/24 between 11:50 AM to 11:54 AM, R9 was observed in her bed that was in a high position. At 11:50 AM, V13 (Certified Nursing Assistant/CNA) had started to provide incontinence care for R9, when V13 stopped and said she needed to go get assistance, leaving R9 in her bed, with the bed in a high position. At 11:54 AM, V13 and V14 (CNA) returned to R9's room to continue incontinence care. On 02/20/24 at 12:03 PM, V13 said she had meant to put R9's bed back in a low position. V13 said that R9's bed should not have been left in a high position because it is a fall risk. On 02/22/24 at 10:06 AM, V2 (Director of Nursing/DOM) said the staff should not have left R9 in a high position when she went to go get help because it is a fall risk and possible injury. 2. On 02/20/24 at 10:45 AM, R29 was observed in bed with the bed in a high position. On 02/21/24 at 11:53 AM, R29 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-04-05 · tag F0882 — widespread
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to have a Certified Infection Preventionist to oversee the Infection Control Program of the facility. This applies to all residents residing in the facility. The findings include: The Census and Condition report dated 4/4/23 show there are 137 residents residing in the facility. On 4/4/23 at 9AM, V2 (Director of Nursing/DON) and V4 (Infection Control Nurse) both said they are not Certified Infection Control Preventionist (IP) and have not taken the required training to become an IP. V4 said the facility's IP was the previous DON. V5 (QA, Payroll Staff) is serving as the IP at the facility and had taken the training. Both V2 and V4 said they were not familiar with V5's qualifications. V2 said V21 (Nurse Supervisor) also went through the IP Nurse training but was not the Infection Control -IP nurse at this time. At 11:10 AM, V5 said she has a degree with Civil Engineer but no degree in Health Sciences. V5 said she has no degree with public health, epidemiology, microbiology, medical technology, or any related fields. V5 said her…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-04-05 · 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 mechanical stand lifts were clean and homelike. This applies to 26 of 26 residents (R5, R15, R20, R25, R40, R41, R47, R52, R56, R57, R58, R59, R62, R64, R74, R77, R79, R81, R83, R87, R90, R91, R93, R99, R100 & R110) reviewed for homelike environment in the sample of 27. The findings include: On April 3, 2023, at 11:57 AM, R81 was being transferred with a mechanical stand lift. The standing platform had food and dried unknown debris caked on it. The stand lift didn't work so it was changed out for another lift. The lift appeared the same, food and unknown dried debris caked on the standing platform. R81 was wearing only socks. On April 4, 2023, at 9:00 AM, a mechanical stand lift remained dirty with food and unknown dried debris caked on the standing platform. At 1:55 PM mechanical stand lifts on the third and second floor were dirty with food and unknown dried debris caked on the standing platforms. The wheels had clumps of hair knotted into the barrels of all the wheels. On April 4, 2023, at 10:34 AM,…

    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 · E2023-04-05 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, interview, and record review the facility failed to ensure a multi-dose vial was dated when opened. This has the potential to affect 22 of 22 residents (R17, R65, R67, R72, R73, R78, R82, R122, R123, R127, R135 & R290-R300) reviewed for medication storage in the sample of 27. The findings include: On April 4, 2023, at 2:02 PM, 2 TB (tuberculosis) multi dose vials were in the first-floor refrigerator. The vials were opened and not dated. V16 (Registered Nurse) stated, they are supposed to date medications when they open the vial/bottle. Both labels on the TB vials show, discard 30 days after opening. The facility's roster provided on April 5, 2023, shows, R17, R65, R67, R72, R73, R78, R82, R122, R123, R127, R135 & R290-R300 reside on the first floor. The facility's administering medications policy (no date) shows, 8. When opening a multi-dose container, the date shall be recorded on the container.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-05 · 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 observation, interview, and record review the facility failed to ensure a dressing was changed to a resident's pressure ulcer and failed to ensure the dressing was in place to a resident's pressure ulcer. This applies to 1 of 5 residents (R46) reviewed for pressure ulcers in a sample of 27. The findings include: On 4/3/23 at 1:28 PM V13(Certified Nurse Assistant/CNA) transferred R46 to bed using a mechanical lift. R46 had a dressing on right outer knee dated 3/29/23. V13 stated, That is her bone under there. R46's Wound Evaluation and Management Summary dated 3/29/23 shows that R46 has a 1 cm x 0.7 cm x not measurable full thickness wound to her right knee. It is documented as Other viable tissue- 100% (Bone). The objective for this wound is: control infection, palliation. R46's March Treatment Administration Record shows that R46 has an order for: Right Knee: Cleanse with Normal Saline/wound cleanser and pat dry gently. Apply sure-prep skin protectant to the peri wound, apply (petroleum gel) gauze to the wound bed, cover with bordered foam. Every day shift every Monday,…

    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 · D2023-04-05 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 a contracture had a splint applied and failed to provide restorative services for 3 of 5 residents (R35, R60, R131) reviewed for restorative/range of motion in the sample of 27. 1. On 04/03/23 at 10:13 AM, R131 was in sleeping in bed with her right hand resting on her chest. R131's fingers were slightly bent in towards the palm of her hand. There was a blue splint on the nightstand in R131's room. On 04/03/23 at 2:20 PM, R131 was up in a reclining wheelchair in the lounge area. R131 did not have a splint on her right hand. On 04/04/23 at 08:53 AM, R131 was in bed. R131's hand splint was on the nightstand in her room. On 04/04/23 at 9:32 AM, V10 (Registered Nurse) stated R131 has a right-hand contracture. She should have a brace on when she gets up and off at nights. We put it on when she gets in chair in the afternoon. On 04/05/23 at 11:21 AM, V11 (Occupational Therapy) stated R131 has a right-hand contracture. 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 · Dcited before2023-04-05 · 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 transfer a resident in a safe manner for 1 of 27 residents (R23) reviewed for safety in the sample of 27. The findings include: On 04/03/23 at 10:34 AM, R23 was sitting up in her wheelchair, slowly propelling herself down the hall. At 10:36 AM, V6 (Certified Nursing Assistant) assisted R23 to the bathroom in her room. R23 said she didn't want to go to the bathroom, she just wanted to go to bed. V6 than moved R23's wheelchair to the bed. R23 grabbed onto the rail of the bed and half stood up. V6 (with the gait belt around V6's waist) grabbed the back of R23's pants and helped R23 to stand, pivot, and sit down in bed. On 04/04/23 at 01:42 PM, V7 (Registered Nurse) said R23 is a one person for transfers. V7 said everyone should use a gait belt during transfers for safety. R23's Minimum Data Set, dated [DATE] shows R23 is cognitively impaired and requires extensive assistance of two persons for transfer. The facility's Safe Lifting 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 · D2023-04-05 · 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 appropriate care and services were performed to prevent a urinary tract infection or to prevent a urinary tract infection from worsening and failed to ensure an indwelling urinary catheter bag was kept below the level of the bladder to prevent infections for 2 of 27 residents (R42 and R81) reviewed for continence/catheters in the sample of 27. The findings include: R42's Physician Progress Notes from 3/31/23 shows that she has a history of urinary tract infections. R42's Nursing Notes dated 4/2/23 shows, Observed resident calling for bathroom multiple times since this morning more than usual received orders .UA (Urinalysis) with reflex to culture .orders carried out. R42's Nursing Notes dated 4/3/23 shows, Urine collection is still pending. Tried urine collection using specimen hat this afternoon, resident put toilet paper with the specimen. On 4/3/23 at 1:37 PM, R42 was sitting on the toilet. V17 (Certified Nursing Assistant/CNA) lifted her from the toilet using a mechanical sit to stand devices. There…

    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 · D2023-04-05 · 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 that a resident received his medication at the ordered time. This applies to 1 of 27 residents (R38) reviewed for medication administration in a sample of 27. The findings include: On 4/3/23 at 10:51 AM R27 (R38's wife) stated, I don't care for agency nurses. Last night 11-7 the nurse came in and gave me my medicine walked out-never came back for (R38). He still never got his morning medications and that concerns me. (R27 was not aware of what medications R38 was supposed to get.) On 4/3/23 at 11:00 AM R38 returned from a dentist visit. R38 stood up using walker and assist from V12 (Certified Nurse Assistant/CNA). R38 had a lidocaine patch on his left hip patch that was dated 4/2/23. R38's April Medication Administration Record shows that R38 has orders for Aspercreme Lidocaine Patch 4%, Apply to back topically every 12 hours. Apply patch to back at 6:00 AM and remove patch at 6:00PM. On 4/4/23 at 9:54 AM V21 (2nd Floor Nursing Supervisor) stated, I was doing rounds yesterday and (V2 Director 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.

    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

$110,030 in federal fines across 1 penalty.

  • $110,030 — penalty dated 2026-03-26

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to CARMELITE SISTERS FOR THE AGED & INFIRM — 9 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 3 of 52.8+0.2 vs chain
Health inspection 2 of 52.1-0.1 vs chain
Staffing 5 of 53.8+1.2 vs chain
Quality measures 3 of 53.9-0.9 vs chain
The other 8 homes this chain runs (chain average 2.8★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleSince
BANIEWICZ, MARYIndividualCORPORATE DIRECTORsince 04/24/2009
BROWN, ANNIndividualCORPORATE DIRECTORsince 09/17/2002
COLARESI, ROBERTIndividualCORPORATE DIRECTORsince 05/01/2021
DOMINICK, KATHLEENIndividualCORPORATE DIRECTORsince 11/01/2018
DURSO, JOHNIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 03/01/1989
FLYNN, KATHLEENIndividualCORPORATE DIRECTORsince 11/01/2020
HALEY, MARGARETIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 04/08/2021
HAYES, WILLIAMIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 01/01/2013
JONES, RAYMONDIndividualCORPORATE DIRECTORsince 04/13/1997
KASTELIC, JEFFREYIndividualCORPORATE DIRECTORsince 08/09/2023
MCGOWAN, KATHLEENIndividualCORPORATE DIRECTORsince 04/05/2013
MILLINGTON, CHARLESIndividualCORPORATE DIRECTORsince 04/16/2004
SHORT, DANIELIndividualCORPORATE DIRECTORsince 03/01/2018
WEBSTER, ALICEIndividualCORPORATE DIRECTORsince 01/01/2012
DIMARIA, LILLIANIndividualCORPORATE OFFICERsince 04/08/2021
MARRERO, KATHERINEIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/30/2019
THE CARMELITE SISTERS FOR THE AGED AND INFIRMOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/13/1966
KHAN, KALEEMIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2023
VEILLEUX, DORISIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/24/2015
GATHERS, PATRICIAIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 08/20/2025
HEERY, MARYIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 08/20/2025
KASPER, ROSEIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 08/20/2025
MCWEENEY, BRIANIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 08/20/2025
O'BRIEN, DEBORAHIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 08/20/2025
PFEFFER, THERESAIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 08/20/2025
SELECT REHABILITATION, LLCOrganizationADP OF THE SNFsince 02/12/2025
THE CARMELITE SYSTEM INCOrganizationADP OF THE SNFsince 04/04/2013

CMS files one row per role, so the 35 rows in the source record cover these 27 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

$17.1M
Net patient revenuemost recent cost report
-23.7%
Operating marginrevenue minus expenses
$506K
Related-party expense2% of expenses
Who pays — share of resident-days
Medicaid 54%Medicare 7%Other / private 40%

This home reported $506K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$390per resident / day
operating cost
$11,846per month
≈ monthly operating cost
$315per 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 145878. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-16, 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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