Warren Barr Oak Lawn
9401 South Kostner Avenue, Oak Lawn, IL 60453 · For profit - Limited Liability company · 122 certified beds · (708) 423-7882 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2026
- it has 2 actual-harm citations
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
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
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 13.6% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 7.4% | 6.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.9% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 90.5% | 54.2% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.7% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 28.0% | 14.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 7.4% | 18.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 69.6% | 91.8% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 7.9% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 19.8% | 20.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.7% | 21.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.5% | 2.2% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 23.0% | 63.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 32.4% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 8.9% | 13.9% | 12.0% | better |
‡ 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.
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 0.77 therapist hours per resident per day in 2025Q4 — more than 94% of the 13,714 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 24% 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 14% — 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 57.7%CMS range 52.6–63.0 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 13.3%CMS range 11.1–16.0 | 10.7% | Oct 2022–Sep 2024 | worse than U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 59.2% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 60.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 63.7% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 95.9% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 93.0% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | 99.1% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.9% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.5%CMS range 4.4–9.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.01 | 1.02 | Oct 2022–Sep 2024 | CMS 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
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 3.54 hrs/resident/day on weekends vs 3.74 on weekdays — 6% thinner on weekends. RN hours go from 0.89 to 0.70 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 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.
28 citations, most serious first. The 12 most serious are shown; the remaining 16 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 — isolatedProvide 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.
- Actual harm · G2024-07-24 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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.
- Potential for harm · E2026-04-17 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably accommodate the needs and preferences of each resident.
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 call lights were consistently within reach of residents (R23, R150, R64) and failed to ensure that wheelchairs were available for residents (R112 & R143) who were assessed to require them for mobility. This affected five residents (R23, R64, R150, R112, and R143) reviewed for accommodation of needs on the total sample of 43. Findings include: 1.On 4/14/26 at 10:05 AM, R23 was observed lying in bed. R23's call light cord was observed clipped to the cord at the wall. Call light was not within reach. On 4/14/26 at 10:30 AM, R150 was observed sitting in wheelchair next to bed. R150's call light cord was observed in-between R150's headboard and mattress and dangling three inches above the floor. Call light was not within reach. On 4/14/26 at 10:12am, R64 was assessed to be alert and oriented to person, place and time, and was observed in bed, with his call light cord wrapped around the hand sanitizer container which was attached 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.
- Potential for harm · Ecited before2026-04-17 · tag F0880 — failed to prevent and control infections — patternProvide 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 Failures at this level required more than one deficient practice statement:A. Based on observations, interviews, and record reviews, the facility failed to follow its infection prevention and control policy, including its COVID-19 policy. Specifically, the facility failed to place a resident with an indwelling medical device on transmission-based precautions upon admission; failed to don appropriate personal protective equipment (PPE) prior to entering an enhanced barrier precautions (EBP) resident room to provide direct care (R6); failed to place a COVID-19 positive resident in appropriate transmission-based (contact/droplet) precautions immediately upon return from the hospital and initiate the required monitoring protocol (R147); and failed to implement contact tracing for residents and staff exposed to a COVID-19 positive resident. These practices affected two residents (R6 & R147) reviewed for infection control practices on the total sample of 43.B. Based on observation, interview, and record review, 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.
- Potential for harm · D2026-04-17 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 observation, interview and record review the facility failed to ensure residents are not verbally and mentally abused by facility staff. This affected one of three residents (R144) reviewed for staff to resident abuse on the total sample of 43. Findings include:R144 was admitted to the facility on [DATE] with a diagnosis of lumbosacral disc displacement, hyperlipidemia, hypertension and insomnia.R144 Minimum Data Set, dated [DATE] documents brief interview for mental status score was 15/15 which indicates cognitively intact.On 4/15/26 at 1:27PM, Surveyors were walking in the hallway passing R144's room and heard loud arguing. R144's door was open and surveyor observed from the hallway V42 (MDS nurse) and V43(Housekeeping director) standing around R144's bed. V42(MDS nurse) yelled in a stern, loud and dismissive tone I'm done with this and left the room. Surveyors entered R144's room, and R144 was observed in her bed crying with two open bags of her belongings near the foot of the bed. R144 was upset 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.
- Potential for harm · D2026-04-17 · tag F0627 — isolatedEnsure 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
Based on interviews and record reviews, the facility failed to provide and document sufficient preparation/orientation to one resident to ensure a safe/orderly transfer from the facility to the hospital, failed to obtain a physician order for the transfer, and failed to document the transfer in the resident's medical record. This affected one resident (R130) out of three reviewed for transfer/discharge in a sample of 43. Findings include:On 4/17/26 at 8:55 AM, V3 ADON (assistant director of nursing) stated that the nurse is expected to notify the physician and resident's family of a resident's transfer to the hospital. V3 stated that the nurse is expected to follow up with the emergency room staff and call report to the nurse. V3 stated that the nurse is expected to complete an e-interact form and SBAR (situation, background, assessment, recommendation) for every resident. The nurse should also document the change in condition or reason for transfer to the hospital and the resident's vital signs in the resident's progress notes.R130's POS (physician order sheet), dated 3/9/26, notes…
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.
- Potential for harm · D2026-04-17 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — the official record, unedited, may be distressing
Based on interviews and record reviews, the facility failed to provide the bed hold policy to one resident or representative upon transfer to a local hospital. This affected one of (R130) three reviewed for bed hold in a sample of 43.Findings include:On 4/17/26 at 8:55 AM, V3 ADON (assistant director of nursing) stated that the nurse transferring a resident to the hospital is expected to provide the resident and/or the resident's representative with written information on the duration of the bed-hold policy.R130's medical record does not contain any documentation that R130 or R130's family received written information on bed hold.The facility's bed-hold policy, revised 6/26/25, notes the facility must inform the resident or family members being transferred of the duration of bed hold in writing.
- Potential for harm · D2026-04-17 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record reviews, the facility failed to initiate a person-centered care plan for enhanced barrier precautions (EBP) and enteral nutrition for one resident admitted to the facility with a gastrostomy tube and receiving enteral nutrition. This affects one of three (R6) residents reviewed for comprehensive care plan in a sample of 43.Findings include:On 4/14/26 at 10:00 AM, R6 stated that he receives bolus feedings via his gastrostomy tube after meals and at bedtime.R6's POS (physician order sheet) notes an order for enteral nutrition, 360ml (milliliters) bolus feeding after meals and at bedtime daily.On 4/16/26 at 9:30 AM, V12 IP nurse (infection prevention nurse) denied being aware R6 was admitted to this facility with a gastrostomy tube. V12 stated that R6 should have been placed on EBP (enhanced barrier precautions) upon admission due to having a gastrostomy tube. V12 stated that R6 should have a care plan for EBP and gastrostomy tube.On 4/17/26 at 8:55 AM, V3 ADON (assistant director of nursing) stated that the nurse is expected to initiate enhanced barrier…
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.
- Potential for harm · Dcited before2026-04-17 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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.
- Potential for harm · Dcited before2026-04-17 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 follow their physician order to ensure compression wraps were applied as prescribed (R78) and failed to ensure the old Scopolamine transdermal patch was removed before applying a new patch (R148). This affected two of three residents (R78 & R148) reviewed for quality of care on the total sample of 43. Findings Include: R78 was diagnosis with Lyphedema. Brief interview for mental status dated 2/26/26 documents a score of fifteen which indicates cognitively intact. Physician order sheet dated 9/28/25 documents: wrap bilateral lower extremities with Compression wraps with Ace bandage at 0600 (6:00am) in the morning apply. On 4/14/26 at 10:36am, R78 who was assessed to be alert and orient to person place and time said, her ace wraps for her legs was not applied today. R78 was observed without her compression ace wraps in place. R78 opened the top of her nightstand dresser drawer, R78's ace wraps were observed in the drawer. R78 said, she was supposed to have her ace wraps applied to decrease the swelling in her legs. On…
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.
- Potential for harm · D2026-04-17 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide 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 follow the ortho physician recommendations to complete physical therapy evaluation and treat, occupational therapy evaluation and treatment, and assist with passive range of motion including pendulum exercises for greater than 30 days for one of three residents (R7) reviewed for physicians' orders regarding therapy and range of motion on the total sample of 43. Findings include: R7 face sheet shows diagnosis of displaced fracture of upper end of right humerus, initial encounter for closed fracture 3/5/26. On 4/14/26 at 11:48am R7 observed alert to person, place, time and situation. R7 observed with a black sling supporting her right arm. R7 said she'd fallen from bed when she was reaching for her phone to call her brother. R7 lifted her arm and R7 was observed with limitation to the shoulder. R7 said her shoulder was not like that before she fell. On 4/16/26 at 11:40am V7 (Restorative Nurse) said R7 had a fall on 3/5/26, R7 was sent out 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.
- Potential for harm · D2026-04-17 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow their intravenous therapy policy by failing to ensure one resident's Peripherally Inserted Central Catheter (PICC) dressing was changed every 7 days. This affects one of one residents (R121) reviewed for intravenous therapy on the total sample of 43. Findings include:R121 was admitted to the facility on [DATE] with diagnosis polyneuropathy, infection and inflammatory reaction due to internal left knee prothesis and anemia.On 4/14/26 at 11:40AM, R121 was in his room up to wheelchair. R121 had a t-shirt on and observed Peripherally Inserted Central Catheter to his right upper arm. There was a clear dressing over the insertion site that was rolled up around the outer edges around the entire dressing. There was a date of 3/19/26 on the dressing. R121 said no one has touched his Peripherally Inserted Central Catheter (PICC) Line site for a while and wasn't sure why It was there. On 4/14/26 at 12:13PM, V2 (Director of nursing, DON) 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.
Show the remaining 16 citations
- Potential for harm · D2026-04-17 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that an opened insulin vial was properly labeled with the date opened and/or expiration date, in accordance with medication storage policy. This affected one of one resident (R61) reviewed for medication storage on the total sample of 43. Findings Includes: R61 was diagnosed with type two Diabetes Mellitus with Diabetic Autonomic (Poly) Neuropathy. Physician order sheet dated 4/2026 documents: Insulin Lispro Injection Solution 100unit/ milliliter On [DATE] at 10:51AM, during medication cart audit with V45 (nurse), R61 lispro insulin vial was open and not dated. V45 (nurse) confirmed there was no open date or expiration date on the insulin bag or vial. On [DATE] at 12:22pm, V2 (director of nursing) said, when insulin is open she expects nursing to write and open and expired date on the insulin so that it is used it not used after twenty-eight or thirty days. V2 said, she does not have an insulin policy and uses the medication…
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.
- Potential for harm · Dcited before2026-04-17 · tag F0773 — isolatedProvide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
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 doctor orders to order a stat lab draw for one resident(R142) for one of one reviewed for lab services on the total sample of 43. Findings include:R142 was admitted to the facility on [DATE] with a diagnosis of alcoholic polyneuropathy, cirrhosis of liver, and hyponatremia.On 4/15/26 at 4:14PM, V15 (nurse) said upon starting her shift on 4/14/26 V25(unit manager) informed her that R142 had orders for stat blood work due to change in condition. V15 said V25 put in order for lab orders. V25 called around 5 or 6 to see if lab had come yet and added more orders. V15 said the family called and said they did not want to wait anymore for lab services and called 911 from their home. R142 was transferred to the hospital.On 4/16/26 at 11:40PM, V25(unit manager) said she put in stat orders for the R142's blood work per doctors orders. V25 said she informed V15(nurse) about the orders. V25 said later that evening the family said they did not want to wait…
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.
- Potential for harm · D2026-04-17 · tag F0777 — isolatedProvide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
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 interviews, the facility failed to ensure contracted diagnostic services were provided within 24 hours, as required under the terms of its contractual agreement, for one resident with a history of pulmonary embolism and acute embolism. This affected one of one resident (R143) reviewed for diagnostic services on the total sample of 43. Findings include:R143 was admitted on [DATE] with hemiplegia and hemiparesis following nontraumatic intracerebral 03/08/2026 primary hemorrhage affecting right dominant side, pulmonary embolism without acute pulmonale, acute embolism and thrombosis of right peroneal vein, and aphasia following cerebral infarction. R143's progress notes dated 4/13/26 at 4:31 PM (16:31) documents: R143 endorses pain to left lower extremity and swelling noted. V40(MD) made aware and ordered doppler of left lower extremity. R143's physician order dated 4/13/2026 4:34PM (16:34) documents left duplex scan, veins, extremity, unilateral/limited study. On 4/15/2026 at 10:30 AM, V2…
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.
- Potential for harm · Dcited before2025-12-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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.
- Potential for harm · D2025-11-18 · tag F0697 — failed to manage pain — isolatedProvide 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.
- Potential for harm · Dcited before2024-07-24 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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.
- Potential for harm · E2024-04-05 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop 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.
- Potential for harm · D2024-04-05 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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.
- Potential for harm · D2024-04-05 · tag F0583 — failed to protect personal privacy — isolatedKeep 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.
- Potential for harm · Dcited before2024-04-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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.
- Potential for harm · D2024-04-05 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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.
- Potential for harm · D2024-04-05 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure 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.
- Potential for harm · Ecited before2024-03-20 · tag F0880 — failed to prevent and control infections — patternProvide 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 covid 19 testing policy by not testing residents and staff following a covid 19 outbreak on 9/8/23 which had the potentially to affect all the 103 residents. In addition, the facility failed to test residents and staff for covid 19 for 14 days with no new positives during an outbreak that started on 2/5/24 which had the potential to affect all 96 residents at the facility reviewed for infection control. Findings include: Facility staff covid line list dated August 1st until September 30 2023 documents: V48 (Speech) tested positive for covid 19 on 9/11/23. V49 (nurse) tested positive for covid 19 on 9/8/23. V48 (Speech) time punches document last day worked prior to positive testing was 9/7/23 8:38AM to 4:03PM. V48 provided speech services to 13 residents on 9/7/23 per daily labor report dated 9/7/23. On 3/12/24 at 12:02PM, V48 (speech) said on 9/10/23 he was symptomatic while at home and tested positive for covid using a rapid test. He…
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.
- Potential for harm · D2024-03-20 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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 interviews and record reviews, the facility failed to notify attending doctor of an outside consultant order/recommendations. This deficient practice affects one resident (R18) of three residents reviewed for physician notification. Findings Include: R18 is a [AGE] year old with diagnoses but not limited to: Acute Diastolic Congestive Heart Failure, Arteriosclerotic Heart Disease of Native Coronary Artery, Multiple Sub segmental Pulmunary Emboli, Acute Embolism and Thrombosis Deep Vein of Right Lower Extremity. R18 hospitalized on [DATE] for chest tightness and was diagnosed with bilateral proximal pulmonary artery emboli with right heart stain, underwent thrombectomy. Returned in the facility on 1/23/23, and was place on anticoagulant medication. R18 went to see Cardiologist on 6/1/23 and returned with an order of: May discontinue Eliquis (Anticoagulant) medication on 7/18/23 and follow up with cardiologist in 6 months. Nurse notes dated 6/1/23, reads in part: R18 returned from cardiologist. New orders…
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.
- Potential for harm · Dcited before2024-03-20 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 follow physician orders by not applying an antifungal cream to one resident. This affected one of three residents (R3) reviewed for medication. Findings include: R3 readmission hospital paperwork dated 9/15/23 documents orders for: antifungal cream apply three times daily. R3's physician order dated 9/15/23 with start date of 9/16/23 for antifungal ointment apply to affected area three times a day for fungal infection R3 medication administration record for September 2023 documents: antifungal ointment apply to affected area three times a day (0600, 1400, 2100) for fungal infection with start date of 9/16/23 and discontinued on 9/19/23. The 0600 dose on 9/16/23- 9/19/23 documents NN (nurses notes) which indicates to see nursing notes. R3's nursing notes dated 9/16/23 documents: antifungal cream on order. R3's nursing notes dated 9/17/23 documents: medication unavailable. R3's nursing notes dated 9/18/23 documents order with no other documentation. R3's nursing notes dated 9/19/23 documents: medication unavailable. On 3/1/24…
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.
- Potential for harm · Dcited before2024-03-20 · tag F0773 — isolatedProvide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record reviews, the facility failed to notify the attending physician of one resident's urine culture and sensitivity results noting the antibiotic the resident was receiving for UTI (urinary tract infection) was ineffective in treating resident's UTI. This affected one of three residents (R10) reviewed abnormal labs on the sample list of 49. Findings include: On 3/12/24 at 1:07 PM, V51 (attending physician) stated that typically V51 will order macrobid (antibiotic medication) for UTI (urinary tract infection) until the urine culture and sensitivity results are known. V51 stated that it takes 3-4 days for culture results and V51 does not want to wait to start treatment. V51 stated that macrobid treats most UTIs. V51 stated that V51 expects the nurse to call him with the urine culture and sensitivity results once results are known so antibiotic can be changed if the current antibiotic is not effective in treating UTI. V51 stated that V51 does not recall R10. V51 was informed that R10 had urine for a urinalysis collected on 9/21/23 with results noting UTI on…
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.
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to LEGACY HEALTHCARE — 95 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.9 | +1.1 vs chain |
| Health inspection | 4 of 5 | 2.8 | +1.2 vs chain |
| Staffing | 2 of 5 | 2.5 | -0.5 vs chain |
| Quality measures | 3 of 5 | 3.3 | -0.3 vs chain |
The other 94 homes this chain runs (chain average 2.9★, per CMS)
Showing 40 of 94; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| DOROS GENERATION TRUST U/A/D 1/3/12 | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 26% | since 02/01/2023 |
| GPN FAMILY TRUST U/A/D 4/28/08 | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 60% | since 02/01/2023 |
| OAKWAY OPERATIONS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 15% | since 02/01/2023 |
| BENCO, JENNIFER | Individual | W-2 MANAGING EMPLOYEE | — | since 02/01/2023 |
| SHABAT, MENACHEM | Individual | CORPORATE OFFICER | — | since 02/01/2023 |
| LEGACY HEALTHCARE FINANCIAL SERVICES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 02/01/2023 |
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
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.
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 2026-09-01 — CMS provider number 145363. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-17, 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.