Warren Barr Oak Lawn

Location & what’s nearby

Open in Google Maps ↗ · Directions ↗ · Larger map ↗

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

Quality measures — how residents actually fare

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.

57.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 469 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 59.2% 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 223 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 0.74 therapist hours per resident per day in 2026Q1 — more than 93% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 26% 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.

Staffing

How full it usually is: this home is certified for 122 beds and averages 110.1 residents a day — about 90% occupied, or roughly 12 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.52 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.81 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.94 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.41 hrs/resident/day on weekends vs 3.57 on weekdays — 4% thinner on weekends. RN hours go from 0.83 to 0.74 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%.

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

Inspection trend

Deficiencies are 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.

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.

22 citations, most serious first. The 14 most serious are shown; the remaining 8 are one tap away and print in full.

• Actual harm · Gcited before2024-07-24 · 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 recognize an acute change in condition for a resident. This failure applied to one (R5) of three residents reviewed for nursing care and resulted in a delay in care for R5 who was hospitalized for respiratory failure. Findings include: R5 is [AGE] years old and admitted to the facility on [DATE] and has diagnoses that include hydrocephalus, g-tube placement, communication deficit weakness and lack of coordination. Minimum data set (6/28/24) indicates R5 to have severe cognitive impairment and unable to make needs known to staff. The assessment data also includes that R5 is incontinent of bowel and bladder and totally dependent on staff for turning, repositioning and all other activities of daily living. On 7/15/24 at 12:51PM R5 was in the facility, observed by the Surveyor to be in bed, and appearing to be in respiratory distress. R5 was visibly and audibly gasping for air and respirations were counted at 47 breaths per minute. At 12:55PM…

  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 · G2024-07-24 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement turning and repositioning to prevent the development of new pressure injuries and complete treatment orders. This failure affected two residents (R4 and R5) who were at high risk of developing pressure ulcers and resulted in R4 and R5 developing deep tissue injuries to the sacrum. Findings include: R4 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that included Protein-calorie Malnutrition, Heart failure, and metabolic encephalopathy. According to Skin Evaluation Assessment of 3/13/24, R4 was assessed to have one pressure ulcer of the right heel. Minimum Data Set (3/25/24) indicated R4 was cognitively impaired, incontinent of bowel and bladder and dependent on staff for turning, repositioning and toileting. R4 used a manual wheelchair, to which they were dependent on staff to transfer and maneuvers. R4 was able to feed self with set-up assistance from the staff. The mobility task for R4 was reviewed for March 2024.…

  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 · G2022-12-22 · tag F0726 — failed to have competent, trained nursing staff — isolated
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that nursing staff had the required competencies when transcribing physician orders for newly admitted residents to ensure that care is being provided as ordered and to meet the needs of the residents; they also failed to ensure that standards of nursing practice were being followed during the administration of medication. This failure applied to three of three (R73, R103, and R504) residents reviewed for nursing services and resulted in (R73) receiving medication that was not ordered; (R103) not having a BiPap machine upon admission, that R103 was required to wear due to history of sleep apnea and respiratory failure; and (R504) did not receive medication that were needed for the prevention of blood clots upon admission to the facility. Findings include: R103 was a [AGE] year-old male initially admitted to the facility on [DATE] and expired on [DATE]. His medical diagnoses include but are not limited to the following: respiratory…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2022-12-22 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  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 accurately transcribe hospital discharge orders to ensure that a newly admitted resident received all medications needed for treatment and failed to prevent a medication administration error. These failures affected two residents (R504 and R73) reviewed for medication administration and resulted in one resident (R73) receiving medication that was not ordered and resulted in (R504) not receiving medication for the prevention of blood clots upon admission to the facility and then being emergently transferred to the hospital and subsequently expiring. Findings include: R504 was an [AGE] year old male admitted to the facility [DATE] with diagnoses that included cerebral infarction and hypertension. Immediately prior to transfer, R504 underwent a surgical laminectomy of the spine after sustaining a fall in the home. According to the Minimum Data Set assessment dated [DATE], R504 was assessed to be totally dependent on staff for all activities of daily…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-17 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow its incontinence care policy and failed to ensure that a resident identified as requiring assistance with toileting was assessed and provided incontinence care at least every two hours. This affected one of three residents (R135) reviewed for incontinence care on the total sample of 43. Findings Includes: R135's minimal data set dated [DATE] section C (cognitive pattern) brief interview for mental status documents a score of twelve which indicate moderate cognitive impairment. Section GG (functional ability) documents: lower extremities impairment on both sides. R135 requires substantial maximal assistance rolling left to right and partial/moderate assistance for toilet hygiene. Section H (bladder and bowel) documents urinary continence always incontinent. On 4/14/26 at 11:35am, R135 who was assessed to be alert and oriented to person place and time, said he has not been provided incontinence care since yesterday evening. R135…

  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 before2025-12-26 · 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 the interview and record review, the facility failed to follow its fall occurrence policy by not conducting a post-fall investigation to determine the reasonable cause of the fall and reviewing the fall care plan with new interventions. This applies to one of three residents (R2) reviewed for falls in a sample of 14.The findings include:R2 was a [AGE] year-old male admitted on [DATE] with an admitting diagnosis including dementia, hemiplegia, hemiparesis, heart failure, and urinary tract infection (UTI).A review of the fall log and nursing progress notes documented that the two falls occurred to R2 on 10/30/25 and 11/7/25.On 12/24/25 at 12:25 PM, V2 (Director of Nursing/Fall coordinator) stated, I am the one investigating after a resident fall and then revising the fall care plan with new interventions. I don't have the post-fall investigation completed for R2 for the falls on 10/30 and 11/7. I know I am supposed to investigate and update the fall care plan with new interventions based on the root cause…

  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 · D2025-11-18 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews and record reviews, the facility failed to follow physician orders to ensure as needed pain medication (oxycodone) was administered to one resident as prescribed. This affected one of three residents (R1) reviewed for pain management. This failure resulted in R1 being admitted to this facility on 9/24/25 and requested narcotic pain medication, rated pain as 6 out of 10, but was informed by nurse R1's medication was not available until the next morning.Findings include:On 9/30/25 at 10:55 AM, R1 stated that R1 was admitted to this facility on Wednesday, 9/24/25. R1 stated that she asked for oxycodone (pain medication) and was informed that her medications had not been delivered yet. R1 stated that R1's oxycodone was delivered (on 9/25/25), and she received a dose around 9:00 AM.On 9/30/25 at 1:50 PM, V2 DON (director of nursing) stated that the nurse is expected to sign out medications on the controlled substance sheet and MAR (medication administration record) when a narcotic (oxycodone) is being administered. V2 stated that the medications are to be removed 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 before2024-07-24 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide timely incontinence care assistance for one of three residents (R8) reviewed for incontinence care. Findings include: R8 is [AGE] years old and admitted to the facility with diagnosis that include peritonitis, difficulty walking, shingles, COPD and heart failure. R8 was also experiencing a infection of the bowels that causes frequent loose stools. Minimum Data Set 7/10/24 noted that R8 lacks any cognitive impairment, is incontinent of bowel, has an indwelling urinary catheter and requires physical assistance from staff for activities of daily living. On 7/18/24 at 10:17AM R8 was observed in bed, alert and coherent. The call light was activated, and V11 Unit Nurse Manager was observed donning an isolation gown. V11 went in to address R8, turn the light out and left. R8 requested incontinence care. At 10:25AM, R8 was interviewed and said, that the nurse came in and said that the CNA (Certified Nursing Assistant) was busy and that they would come…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-04-05 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
  Develop and implement policies and procedures for flu and pneumonia vaccinations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to offer Influenza and Pneumococcal immunization as required for four of five residents (R25, R,27, R73 and R265) reviewed for immunization in a sample of 20 residents. Findings include: On 4/4/24 at 11:45am, and V2 (Director of Nursing) and V22 (Infection Retentionist) both stated, all immunization given or refused should be documented. V22 stated that, she is responsible for checking that residents' s immunization are up to date once admitted into the facility. During record review on 4/4/2024 at 1:00 PM, R25, R27, R73 and R265' s immunization records did not indicate that these residents received or refused the Pneumococcal vaccine. R27's immunization record had no documentation to indicate that she received or refused the influenza vaccination. Facility policy reviewed 12/12/23 reads: Pneumococcal Vaccination. Policy statement: It is the policy of the facility to offer and administer Pneumococcal vaccination to each resident as recommended by CDC's Advisory Committee on Immunization Practices (ACIP), unless otherwise…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-04-05 · 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 ensure that the urine collection bag was covered for two of two residents (R261, R264) reviewed for resident's rights in a sample of 20. Findings include: 1. On 04/02/2024 at 7:22AM during unit rounds, R261 was observed lying on bed with urine collection bag placed on the side of the bed that is facing the hallway, uncovered. R261's door was also observed wide open. R261's room is a 2-bed room and has a roommate. On 04/02/2024 at 10:48AM during observation with V10 (Registered Nurse), R261 was observed sitting on his wheelchair with urine collection bag uncovered. On 04/02/2024 at 10:48AM during interview with V10, V10 stated that R261's urine collection bag should be covered. On 04/04/2024 at 9:29AM during interview with V2 (Director of Nursing), V2 stated that all urine collection bags should be covered to maintain resident's dignity. Review of R261's Order Summary Report dated 04/04/2024 indicated admission date on 03/29/2024 and diagnoses of not limited to chronic kidney disease, stage3, and retention 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-04-05 · tag F0583 — failed to protect personal privacy — isolated
  Keep residents' personal and medical records private and confidential.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review the facility failed to ensure privacy was maintained while applying a pain patch for one of one residents (R54) reviewed for privacy in a sample of 20. Findings include: On 4/3/2024 at 8:40am, V16 (Licensed Practical Nurse-LPN) was observed applying a pain patch to R54's left shoulder with the resident's shirt pulled up over her shoulder, the room door was open and the privacy curtain was not closed. R54 said I prefer the pain patch on the left shoulder instead of the right shoulder as indicated. On 4/3/2024 at 8:45am, V16 said I should have closed the privacy curtain and the door then applied the pain patch. On 4/4/2023 at 9:20am, V2 (Director of Nursing-DON) said I would expect the nurses to always provide privacy. An Order Summary report dated 4/4/24 indicates that R54 has a diagnosis of spinal stenosis, lumbar region, with neurogenic claudication and low back pain unspecified, an order dated 3/28/2024 for a Lidocaine Pain Relief 4% Patch to right shoulder topically one time a day for pain and remove per schedule. Facility Policy:…

  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 before2024-04-05 · 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 follow the fall care plan by failing to implement a fall intervention by not ensuring a resident's call light was in reach for a resident (assessed to be risk for fall and history of fall at the facility). This failure affected one resident (R57) of three reviewed for call lights in a total sample of 20. Findings include: On 4-2-24 at 8:05 AM, surveyors noted R57 clean, dressed, and groomed. R57 was up to her wheelchair parked at the side of her bed. Surveyors noted R57's call light in R57's side drawer and out of reach. Surveyor asked V20 (Certified Nurse Aide- Agency) to verify R57's call light and accessibility. V20 verified R57's call light inside of R57's side drawers and not in R57's reach. V20 proceeded to move tray table to retrieve R57's call light and place it in R57's reach. On 4-2-24 at 8:05 AM, R57 said she fell last week because she was reaching for her call light which was on the floor. R57 said she fell out of the bed and…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-04-05 · 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 place a urine collection bag below the bladder for one of two residents (R261) reviewed for catheter use in a sample of 20. Findings include: On 04/02/2024 at 10:48AM during observation with V10 (Registered Nurse), R261 was observed sitting on his wheelchair with urine collection bag placed on the wheelchair seat on R261's left side. On 04/02/2024 at 10:48AM during interview with V10, V10 stated that R261's urine collection bag should be placed below the bladder. On 04/04/2024 at 9:29AM during interview with V2 (Director of Nursing), V2 stated that all urine collection bags should be placed below the bladder. Review of R261's Order Summary Report dated 04/04/2024 indicated admission date on 03/29/2024 and diagnoses of not limited to chronic kidney disease, stage3, and retention of urine. Review of facility's policy entitled Indwelling catheter revised on 7/28/2023 indicated the following: Procedures: 7. Indwelling catheter bag will always be positioned below the bladder region to prevent backflow if the foley…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-04-05 · tag F0693 — failed to provide proper feeding-tube care — isolated
  Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to date and label the enteral tube feeding bottle for one of one resident (R264) reviewed for tube feeding management in a sample of 20 residents. Findings include: On 04/02/2024 at 7:48AM during unit rounds, R264 was observed lying on bed with unlabeled and undated tube feeding attached to gastrostomy tube. On 04/02/2024 at 10:52AM during observation with V12 (Licensed Practical Nurse), R264 was again observed lying on bed with unlabeled and undated tube feeding attached to gastrostomy tube. On 04/02/2024 at 10:52AM during interview with V12, V12 stated that R264's tube feeding bottle should be labeled and dated. On 04/04/2024 at 9:29AM during interview with V2 (Director of Nursing), V2 stated that all tube feeding bottle should be labeled and dated. Review of R264's Order Summary Report dated 04/04/2024 indicated admission date of 3/29/2024, diagnoses of not limited to encounter for attention to gastrostomy, order for enteral feeding with order date of 03/29/2024. Review of facility's policy entitled Enteral…

  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

No federal fines in the current CMS record.

Part of a chain

This home belongs to LEGACY HEALTHCARE — 89 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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

CMS files one row per role, so the 7 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

This home reported $51K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in IL