North Aurora Living & Rehab Ctr

Location & what’s nearby

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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

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.

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.

Therapy staffing: this home’s payroll records show <0.01 therapist hours per resident per day in 2026Q1 — more than 0% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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.

Staffing

How full it usually is: this home is certified for 129 beds and averages 100.7 residents a day — about 78% occupied, or roughly 28 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 1.94 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.59 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 0.97 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 1.94 hrs/resident/day on weekends vs 1.94 on weekdays — about the same on weekends as weekdays. RN hours go from 0.51 to 0.79 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 25% is below the national median of 45%.

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

Inspection trend

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

Inspection deficiencies

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

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.

42 citations, most serious first. The 18 most serious are shown; the remaining 24 are one tap away and print in full.

• Immediate jeopardy · L2024-07-15 · tag F0678 — failed to provide CPR when needed — widespread
  Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
  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 initiate CPR (Cardiopulmonary Resuscitation) for a resident (R1) with full code status (attempt CPR). The facility also failed to have a system in place to ensure that Advance Directives are completed timely and available to direct care staff. These failures resulted in R1 not receiving CPR and expiring at the facility. These failures have the potential to affect all residents residing in the facility. The [DATE], Facility Data Sheet showed 96 residents reside at the facility. These failures resulted in Immediate Jeopardy. The Immediate Jeopardy was noted to begin on [DATE], when R1 was found not breathing and no CPR was initiated. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE], at 9:50 AM. Findings include: 1. R1's admission Record dated [DATE] documents R1 as an [AGE] year-old with diagnoses that include bipolar disorder, dementia, and schizoaffective disorder. On [DATE], R1's paper chart included a green…

  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
• Immediate jeopardy · Kcited before2023-11-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to supervise a newly admitted male resident (R4) with known hyper-sexual behaviors resulting in R4 entering 5 female residents' rooms (R1, R2, R3, R5, R6), sexually abusing (R1), and getting into bed with R2 and touching her shoulder. This applies to 5 of 5 residents (R1, R2, R3, R5, R6) reviewed for sexual abuse in the sample of 6. The Immediate Jeopardy began on October 12, 2023 when R4 was admitted to the facility and direct care staff were not made aware of R4's history of hyper-sexual behaviors, and no interventions were put in place to protect other residents, resulting in a resident being sexually abused. V1 (Administrator) and V2 (DON-Director of Nursing) were notified of the Immediate Jeopardy on October 31, 2023 at 11:45 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on November 1, 2023, but non- compliance remains at Level Two because additional time is needed to evaluate the…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-11-02 · 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 ensure a female resident was protected from a male resident with a known history of hyper-sexual behaviors resulting in the sexual abuse of 1 female resident (R1). This applies to 1 of 5 residents (R1) reviewed for sexual abuse in the sample of 6. The Immediate Jeopardy began on October 12, 2023 when R4 was admitted to the facility and direct care staff were not made aware of R4's history of hyper-sexual behaviors, and no interventions were put in place to protect other residents, resulting in a resident being sexually abused. V1 (Administrator) and V2 (DON-Director of Nursing) were notified of the Immediate Jeopardy on October 31, 2023 at 11:45 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on November 1, 2023, but non- compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2023-10-04 · 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 obtain weekly weights, failed to monitor and review for weight loss, and failed to make recommendations for nutritional support for 1 resident (R90) that resulted in a severe weight loss of 23.83% (percent) over 4 months and required an 8-day hospitalization for treatment of rhabdomyolysis and hypokalemia. The facility also failed to complete a quarterly dietary assessment for 1 resident (R33) with a history of significant weight loss. Four residents were reviewed for weight loss in the sample of 20. The Immediate Jeopardy began on 5/5/23 when R90's weight decreased by 11.4% in one month and the physician/nurse practitioner (NP) were not notified and V3 Dietitian, did not identify or address the significant weight loss until 5/22/23. V1, Administrator, was notified of the Immediate Jeopardy on 10/3/23 at 9:38 AM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 10/4/23 at 1:25 PM, but noncompliance…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-04-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to safely transfer a resident (R1) with the use of a mechanical lift. This failure resulted in the resident falling and sustaining fractures to the right hip, left pelvis, pubic bone, and lumbar vertebra. This applies to 1 of 3 residents (R1) reviewed for accidents. The findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE] with multiple diagnoses including generalized edema, chronic pain, impaired mobility, and generalized weakness. R1's MDS (Minimum Data Sheets) dated 3/19/2025 shows R1 was dependent on staff for transfers and required the use of a mechanical lift. On 4/07/2025 at 11:25 AM, V6 (Certified Nurse Assistant/CNA) was interviewed regarding R1's fall incident on 3/31/2025. V6 said she secured R1's sling to the mechanical lift to transfer him from the bed to his wheelchair. V6 said V4 (CNA) then came to the room and stood behind R1's wheelchair as she started to operate the lift. V6 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-01-05 · 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's rights to be free from sexual and physical abuse by another resident in accordance with facility policy. This applies to 2 of 5 residents (R2 and R5) reviewed for abuse in the sample of 8. This failure resulted in psychological harm to R2 and R5. Both R2 and R5 expressed being scared of their peer who was the perpetrator of the abuse. The findings include: 1). R2's EMR (Electronic Medical Record) showed R2 was [AGE] years old, admitted to the facility on [DATE], with diagnoses of schizoaffective disorder, bipolar type, and tachycardia. On January 3, 2024, at 4:06 PM, R2 stated on December 9, 2024, a female peer R1, came to his room uninvited and would not leave when asked. R1 was a [AGE] year-old female. R2 stated while he was escorting R1 out of his room, while they were both walking toward the door, R1 turned and grabbed R2's genitals through his clothing. R2 stated he pushed R1's hand away. R2 stated he felt scared because after…

  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 before2024-06-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure staff used the wheelchair's footrests during transportation. This failure resulted in R4 falling from the wheelchair to the floor sustaining a forehead laceration and transfer to the emergency department. This Applies to 1 of 3 residents (R4) reviewed for falls and accidents in a sample of 10. A care plan revised on 04/24/2024 showed that R4 has risk factors that require monitoring and intervention to reduce the potential for self-injury. The updated care plan on 06/19/2024 instructed staff to instruct and help R4 use footrests when he is in his wheelchair. The MDS (Minimum Data Set), dated 05/27/2024, showed that R4 was cognitively severely impaired and dependent and required substantial assistance for ADLs, requiring two or more staff members to complete activities such as transfers, dressing, personal hygiene, bathing and ambulation or walking required moderate to partial assistance, and activity was not attempted. A review of R4's face sheet…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-03-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident with a history of falls was provided hourly rounding as ordered by the physician and failed to implement new, individualized fall risk interventions for residents who experienced falls, to prevent further falls. This failure resulted in R1 experiencing an unwitnessed fall at the facility and sustaining a subdural hematoma and R2 falling and sustaining a laceration requiring closure with sutures. This applies to 3 of 3 residents (R1, R2, and R3) reviewed for resident injury in the sample of 4. The findings include: 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. The EMR continues to show R1 was sent to the local hospital on March 6, 2024 at 6:50 AM due to abdominal distention and did not return to the facility. R1 had multiple diagnoses including, bipolar type schizoaffective disorder, COPD (Chronic Obstructive Pulmonary Disease), insomnia, dementia, mixed anxiety disorders, asthma,…

  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 before2026-06-25 · tag F0755 — failed to provide safe pharmacy services — pattern
  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 interview and record review, the facility failed to ensure medications were obtained from the pharmacy in a timely manner to prevent residents from missing medications doses as ordered by the physician. This applies to 4 of 4 residents (R1, R2, R3, and R4) reviewed for pharmacy services in the sample of 4.The findings include:1. R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, major depressive disorder, attention-deficit hyperactivity disorder, and borderline personality disorder. R1's MDS (Minimum Data Set) dated June 17, 2026, showed R1 was cognitively intact. R1's Physician Orders dated June 25, 2026, showed an order dated March 28, 2025, for diclofenac sodium 75 mg (milligram), delayed release, give one tablet by oral route two times per day. R1's April 2026 MAR (Medication Administration Record) showed on April 10, 2026, R1 did not receive the 9:00 AM dose of diclofenac. V8 (LPN/Licensed…

  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 · F2025-12-04 · 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 sanitize dishes during dishwashing procedure.This applies to all 99 residents that received meals prepared and served in the facility kitchen. The findings include: The CMS-671 Form dated December 1, 2025, showed the facility census was 99 residents. Facility provided information that the facility has no residents on NPO (nothing by mouth) status. On December 01, 2025, starting at 9:35 AM, during initial tour of kitchen the following observations were made:In the dry storage area, there were two dented cans placed on shelving with other cans. One of these dented can's contained Marinara sauce (6 lbs./pounds, 9 oz/ounces) with delivery date October 31, 2025, and the other dented can contained cut waxed beans (6 lbs., 5 oz) with delivery date November 12, 2025.In the kitchen, V13 (Dietary Aide) was washing dishes in the dish machine. When asked if the dish machine was a high temperature or low temperature machine, V13 stated she is not sure and that she checks the sanitation using a test strip. On request, V13…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-12-04 · 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 interview and record review, the facility failed to implement their water management program plan, failed to conduct risk assessment to identify high risk areas, failed to document description of the facility's water system, and failed to implement control measures to prevent Legionella and other opportunistic waterborne pathogens spread within the facility's water system.This applies to all 99 residents who reside at the facility.The findings include:Form CMS (Centers for Medicare and Medicaid Services)-671 (Long Term Care facility application for Medicare and Medicaid) dated December 1, 2025, showed the facility had a total census of 99 residents.During the survey, the facility did not have documentation to show water flow schematics of the facility and did not have documentation of an assessment identifying where high-risk water flow areas were in the facility. The facility did not have documented risk assessments or control measures established to handle potential hazards. The facility did not have a plan in place to assess, mitigate risk, and/or monitor for Legionella…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-12-04 · tag F0740 — failed to provide behavioral / mental-health care — pattern
  Ensure each resident must receive and the facility must provide necessary behavioral health care and 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 provide behavioral health services to residents with SMI (severe mental illness).This applies to 4 of 4 residents (R4, R12, R85 and R97) reviewed for behavioral health services in the sample of 23.The findings include:1. R12 was admitted to the facility on [DATE]. R12 had multiple diagnoses including severe bipolar disorder with psychotic features, recurrent severe major depressive disorder without psychotic features, attention-deficit hyperactivity disorder and suicidal ideations, based on the face sheet. R12 is [AGE] years old. R12's admission MDS (minimum data set) dated October 22, 2025, showed the resident was cognitively intact. The MDS showed R12 had no functional limitation in range of motion, and he required supervision from the staff with his ADLs (activities of daily living). Further review of the same MDS showed R12's primary SMI (severe mental illness) diagnosis are recurrent major depression and bipolar disorder I mixed,…

  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 before2025-12-04 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  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 that resident bathroom had a clean and working toilet. This applies to 2 of 3 residents (R78 and R91) reviewed for environmental concerns in the sample of 23. The findings include: On December 1, 2025, at 1:15pm both R78 and R91 were lying on their beds in their room. R78 and R91 were alert and oriented. R78 pointed towards a sign posted on the bathroom door that read, Temporarily Out of Order. R78 said the toilet has not been working for a few weeks. R78 stated, The toilet does not flush and whatever is in there just sits there. Eventually it may go down but the next time you try to flush it again it won't flush. R78 said the sign was put on the door last week by the maintenance staff who said they would fix it. R91 said the toilet had been broken for about three weeks. R91 said that maintenance was informed again at the resident council meeting on November 25, 2025. The note was placed after resident council, but the toilet was still not fixed. R91 said they have been using different restrooms…

  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 · D2025-12-04 · 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 repair a gap between the outside wall and the air conditioner unit on the exterior wall in a residents room, that caused cold air from the outside to flow directly into the room and failed to implement a system to notify maintenance staff of needed repairs.This applies to 1 of 3 resident (R31) reviewed for environmental concern in the sample of 23.The findings include: R31's medical record showed R31 was [AGE] years old. R31 was admitted to the facility on [DATE]. R31 had multiple diagnoses including schizophrenia, alcohol induced psychosis, anxiety disorder and nicotine dependence unspecified. R31's MDS (Minimum Data Set) dated October 29, 2025, showed R31 was cognitively intact. On December 1, 2025, at 10:33 AM, there was a gap in the exterior wall, on the left side, next to the air conditioner in R31's room and the parking lot was visible through the gap. The room was noted to be chilly, and a breeze was noted coming from the gap. R31…

  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 · D2025-07-17 · tag F0627 — isolated
  Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
  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 meet the requirements for an emergency involuntary transfer and did not allow the resident to return to the facility.This applies to 1 of 3 residents (R1) reviewed for involuntary discharge in the sample of 3.The findings include:R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including schizoaffective disorder, bipolar disorder, chronic obstructive pulmonary disease, and type 2 diabetes mellitus. The EMR continued to show R1 was transferred to the local hospital on July 7, 2025, and did not return to the facility.R1's MDS (Minimum Data Set) dated June 17, 2025, showed R1 was cognitively intact, and R1 required partial assistance from facility staff for eating, oral hygiene, toileting hygiene, and personal hygiene. On July 15, 2025, at 2:54 PM, V2 (DON/Director of Nursing) said on July 7, 2025, R1 asked V2 for more food and V2 instructed R1 he already a double portion meal. V2 said she told…

  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 before2025-04-18 · 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 prevent the physical abuse of residents per facility policy. This applies to 2 of 3 residents (R1 and R2) reviewed for abuse in a sample of 3. The findings include: Face sheet, dated 4/17/25, shows R1's diagnoses included Schizoaffective disorder, bipolar type, anxiety disorder, attention-deficit hyperactivity disorder, Major depression disorder, insomnia, obesity, and chronic obstructive pulmonary disease. MDS (Minimum Data Set), dated 3/17/25, shows R1 was cognitively intact. Face sheet, dated 4/17/25, shows R2's diagnoses included dementia with other behavioral disturbance, schizophrenia, difficulty walking, unsteadiness on feet, weakness, foot drop, abnormality of gait and mobility, disorganized schizophrenia, major depressive disorder, and insomnia. MDS, dated [DATE], shows R2 was cognitively intact. Facility Final Incident Investigation Report, dated 4/15/25, shows on 4/12 25 at 10:10 PM, R2 entered the community bathroom where R1 was taking 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-04-08 · tag F0908 — failed to keep essential equipment working — isolated
  Keep all essential equipment working safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow manufacturer's maintenance recommendations for the safe use of a mechanical lift-sling transferring device. This applies to 1 of 3 (R1) residents reviewed for transfer equipment. Findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE] with multiple diagnoses including generalized edema, chronic pain, impaired mobility, and generalized weakness. R1's MDS (Minimum Data Sheets) dated 3/19/2025 shows R1 was dependent on staff for transfers and required the use of a mechanical lift. On 4/07/2025 at 11:25 AM, V6 (Certified Nurse Assistant/CNA) said on 3/31/2025 she and V4 (CNA) transferred R1 from the bed to his wheelchair. V6 said she secured R1's sling to the mechanical lift. V6 said she then started to maneuver and turn the machine when the sling's lower left strap suddenly ripped and R1 fell on the floor. V6 said R1's sling was worn out from overuse because it had not been replaced since R1'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
• Potential for harm · Dcited before2025-03-27 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility failed to schedule a follow up doctor appointment for 1 of 3 residents (R1) reviewed for quality of care in the sample of 10. The findings include: R1's Face Sheet showed a diagnosis of stress fracture of the left radius. On 3/27/25 at 9:50 AM, V6 (R1's Mother) said R1 broke her arm, and the facility did not schedule R1's follow up appointment. On 3/27/25 at 9:30 AM, V4 (Transportation Scheduler) said she schedules residents follow up appointments. V4 said R1's last orthopedic appointment was on 2/25/25 and R1 was taken by the facility's ADAPT (Psychosocial Rehabilitation) staff. V4 said R1 did not have a follow up orthopedic appointment scheduled. On 3/27/25 at 10:50 AM, V8 (Program Director for ADAPT) said an ADAPT staff took R1 to the orthopedic appointment on 2/25/25. V8 said the after visit summary paperwork indicated R1 was to have a follow up appointment scheduled on the week of March 17th. V8 said the after visit summary was given to V3 (Registered Nurse). On 3/27/25 at 10:55 AM, V3 said R1 was to have a follow up orthopedic…

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

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

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

Fines & penalties

$96,800 in federal fines across 3 penalties. 1 Medicare payment denial on record.

• $18,000 — penalty dated 2025-03-27
• $5,000 — penalty dated 2024-11-15
• $73,800 — penalty dated 2023-10-04
• Medicare payment denial — starting 2023-10-25 for 66 days

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

Who owns this facility

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

What families pay in IL