Harmony Park Ridge

Location & what’s nearby

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

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

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

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

51.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 249 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 10.0% 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 60 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 0.36 therapist hours per resident per day in 2026Q1 — more than 62% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 23% 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 298 beds and averages 138.9 residents a day — about 47% occupied, or roughly 159 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.19 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 1.04 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.68 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 3.13 hrs/resident/day on weekends vs 3.22 on weekdays — 3% thinner on weekends. RN hours go from 1.04 to 1.07 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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 unchanged from the previous inspection. 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.

45 citations, most serious first. The 21 most serious are shown; the remaining 24 are one tap away and print in full.

• Actual harm · Gcited beforedisputed · IDR2026-04-23 · 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 ensure necessary services and treatment were provided to prevent the development and/or worsening of pressure injuries for one (R2) of three residents reviewed for pressure ulcers. This failure resulted in R2 developing a Stage 3 pressure ulcer to the left buttock and a Stage 4 pressure ulcer to the right buttock while residing in the facility.Findings:R2 was a [AGE] year-old resident. admission nursing note dated 02/05/2025 documented incontinence and slight redness to the sacral area. A skin assessment completed the same date indicated pressure ulcers to the right and left buttocks.On 04/20/2025 at 1:45 PM, V4 (R2's family member) stated R2 had two black holes on their buttocks while they lived in this facility. V4 stated R2 did not come to this facility with wounds but got them while they lived in the facility. V4 stated they visited daily and R2 was typically saturated in urine and sometimes feces. V4 stated the incontinence briefs being used on R2…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-06-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to ensure resident safety by failure to provide 2 persons assist when transferring resident using a mechanical lift. This affected one resident (R1) of three residents reviewed for falls. This failure resulted in resident (R1) falling from mechanical lift and sustaining a left displaced femoral neck fracture. Findings include: R1 was admitted on [DATE] with diagnosis listed in part but not limited to Displaced fracture of base of neck of left femur, unspecified osteoarthritis, encounter for other specified surgical aftercare, hypothyroidism, hemiplegia, unspecified affecting left nondominant side, unspecified dementia, unspecified severity without behavioral disturbance, difficulty in walking, unspecified fall, subsequent encounter. Admission/Baseline care plan dated 2/14/23 indicated at risk for falls with interventions monitor residents' position when changing in bed, falling star program. ADL care plan dated 2/17/22 indicates requires assistance…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-04-06 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to protect a resident from allegedly being roughly handled, threatened, punched, and intimidated by an agency staff person; failed to assess resident of any injuries; and failed to train staff on screening, abuse prevention and investigation. This failure affected 1 (R1) of 3 residents reviewed for abuse from the sample of 3 and resulted in R1 abruptly ending her rehabilitation to discharge home due to the resident feeling unsafe and distressed for fear of agency staff's return. Findings include: R1 is an alert and cognitively intact resident with diagnoses listed in part with chronic kidney disease, spinal stenosis, hypertension and hyperlipidemia. On 4/4/25 at 11:25 AM, R1 stated upon interview, It was about 4 AM and I had to go to the bathroom, so I did it myself because it seemed there was no one around. No one was at the nursing station when I peeked outside my door plus the hallway was dark and a lot of the lights were turned off. I couldn't get my diaper back on so I put a clean diaper on the bed to lay it down. I went…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-03-14 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and a review of records, the facility failed to follow its weight monitoring policy to prevent or reduce the risk of residents experiencing unplanned significant weight loss. This failure affected three of ten residents (R17, R28, and R61) who were reviewed for weight monitoring and weight loss as part of a sample of 40 residents. As a result, R17 experienced an unplanned weight loss of 6.15% over a 30-day period, R28 experienced a 15.3% weight loss over six months, and R61 experienced an 11.2% weight loss during a six-month period. Findings include: 1) On 3/11/25 at 10:15 AM, R17 was observed to be on a pureed diet with nectar thick liquids. R17 was observed attempting to self-feed breakfast. R17 was observed to have only consumed 20% of breakfast. Staff were not observed assisting R17 with meal or encouraging R17 to eat. On 3/12/25 12:27 PM, Staff were not observed assisting R17 with meal or encouraging R17 to eat. On 3/12/25 at 10:45 AM, V8 RD (registered dietitian) reviewed…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-12-26 · 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 interview and record review, facility staff V3 (Certified nursing assistant, CNA) failed to report a fall to the nurse for one resident (R2). This failure resulted in R2 being transferred back into bed with no nurse assessment for over 10 hours. R2 was transferred to the hospital for a left ear laceration requiring eleven sutures and broken ribs for one of three residents reviewed for falls. Findings include: R2 was admitted to the facility on [DATE] with a diagnosis of Covid 19, urinary tract infection, Parkinson's and overactive bladder. R2 Minimum Data Set, dated [DATE] documents R2 required substantial/maximal assistance (helper does more than half the effort) with sit to stand, chair to bed transfer, and toilet transfers. R2's fall risk assessment dated [DATE] documents: R2 is moderate risk for falls. On 12/26/24 at 3:37PM, V21(former unit manager) said R2 was alert and oriented with periods of confusion. V21 said she went to R2's room around 4:00pm per family's request and daughter showed her R2's…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-06-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to adequately supervise one (R2) resident at risk for falls, a total assist resident and dependent on staff supervision/assistance with all ADL's (Activities of Daily Living); failed to provide assistive device of foot rests on a geriatric wheelchair to prevent sliding/falling; and failed to maintain functionality of bed in order to lower close to the ground. This failure affected one resident (R2) of 9 residents reviewed for accidents/hazards/supervision and resulted in R2 being transferred to the emergency department after a fall from a geriatric wheelchair and diagnosed with a right tibial fracture; and transferred again 11 days later to the emergency department after another fall from a malfunctioning bed. Findings include: R2 is a [AGE] year-old-male with diagnoses including but not limited to hemiplegia, diabetes, neoplasm of prostate, and epilepsy. On 6/11/24 at 10:30 AM, V2 (director of nursing) stated that on 5/23/24 at 2:00 PM, R2 was in the…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-05-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to adequately supervise one (R73) resident who has a history of falls and required staff supervision/assistance with all Activities of Daily Living (ADLs). This failure affected one resident (R73) of seven residents reviewed for accidents and resulted in R73 being diagnosed with a displaced nasal bone fracture. Findings include: R73 is a [AGE] year-old- female who was admitted to the facility on [DATE]. Past medical history includes, but not limited to, progressive supranuclear, dystonia, hyperlipidemia, unsteadiness on feet, need for assistance with personal care, anxiety, essential primary hypertension, etc. R73 has had three falls since January 2024. On 1/16/2024, R73 had an unwitnessed fall while at the nursing station. On 2/16/2024, R73 was found face down while at the nursing station and sustained some injuries on both knees, fall was unwitnessed. On 3/10/2024, R73 was found on the floor in activities room, was sent to the hospital and was treated…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-02-29 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to follow their policy and procedures for abuse prevention by not ensuring an agency staff received a thorough criminal background check, not identifying a resident's behaviors that increase their risk for abuse, and not ensuring an abuse risk or behavior care plan was developed for a resident with a history of refusing care. This failure applied to one of one (R1) resident reviewed for abuse and resulted in R1 being physically and verbally abused and sustaining physical and psychosocial harm. Findings include: R2 is an [AGE] year-old female with a diagnoses history of Cerebral Infarction, Aphasia, Partial Paralysis due to Cerebral Infarction, Dysphagia, and Adult Failure to Thrive, and Major Depressive Disorder who was admitted to the facility 07/08/2020. On 02/26/2024 from 2:38 PM - 2:55 PM Observed R2 in her room sitting up in her bed with her head down in front of a meal tray laying on a bedside table over her bed. Observed R2 could…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-01-21 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to administer physician ordered pain medication consistent with professional standards of practice for a terminally ill resident (R1) of 3 residents reviewed for pain management. This failure resulted in R1 crying and yelling out in extreme pain. The facility also failed to administer pain medications after an unwitnessed fall after showing signs of pain (moaning) and led to adverse consequence of transfer to an acute hospice facility. Findings include: R1 is an [AGE] year-old hospice resident with diagnosis of acute cerebral hemorrhage, congestive heart failure, chronic obstructive pulmonary disease, and chronic back pain. On 1/19/24 at 11:50 AM, V2 (Director of Nursing) was asked for R1's care plans. A review of care plans received from V2 did not have a care plan specific to pain management. Surveyor verified with V2 whether all care plans were received as requested, V2 stated, Yes. I gave you everything. Surveyor asked if pain management was part of…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-10-02 · 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 interview and record review, the facility failed to provide care and services in a timely manner for residents with suspected injuries, who had orders for x-rays and resulted in delay of treatment for injuries. This failure applied to two (R2, R3) of three residents reviewed for resident injury and resulted in R2 and R3 waiting over 24 hours after injury to be transferred to hospital for further evaluation and treatment of fractures. Findings include: 1. R2 was admitted to the facility with diagnoses that include: Parkinson ' s Disease, difficulty walking and gastrostomy tube. Facility provided incident report for incident on 7/28/23, which documented the following: (R2) is AxO (Alert and Oriented) x0. BIMS score of 99. On 7/28/23 around 12:15pm, the resident's daughter notified the nurse that her mother (R2) was yelling when she grabbed her right ankle. Nurse immediately assessed the resident's right ankle and notified the Nurse Practitioner who ordered an Xray of the right ankle. The X Ray results…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-10-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow residents' plan of care by not monitoring a resident (R1) at all times and keeping the resident free from injury; and failed to conduct a proper resident transfer by utilizing only one staff member for a resident (R3) assessed to require two staff members for transfers. These failures applied to two (R1, R3) of three residents reviewed for resident injury and resulted in R1 having an unwitnessed fall in room and obtaining a left wrist fracture and R3 obtaining a right ankle fracture during improper transfer. Findings include: 1. R1 was admitted to the facility with diagnoses that include: cerebral infarction, heart failure, Parkinson's disease, difficulty in walking, and need for assistance. R1 is no longer in the facility and expired on [DATE]. R1's current care plan documents the following: Problem Onset: [DATE] - (R1) is at risk for falls due to decreased safety awareness, decreased strength and endurance, decreased mobility, impaired…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-06-04 · tag F0692 — failed to prevent malnutrition and dehydration — pattern
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were provided with and received adequate fluid intake. This failure applied to four (R1, R4, R6, and R10) of four residents reviewed for hydration. Findings Include: The facility census dated 6/1/2026 shows there are currently 84 residents residing on the second floor who receive fluids by mouth. R10 is a [AGE] year-old female admitted to the facility on [DATE] with a medical diagnosis that includes but is not limited to rheumatoid arthritis, Alzheimer's, Crohn's, hypothyroidism, hypertension, dementia, dysphagia, atrial fibrillation, and depression. On the (MDS) Minimal Data Set assessment of 3/3/2026, section C1000(Cognitive Skills for Daily Decision Making) indicates severe cognitive impairment. On MDS of 3/3/2026 on section GG, Eating Ability, the resident requires partial/moderate assistance. The helper does less than half the effort. Care plan intervention dated 12/14/2025 reads: Monitor intake from meals 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 · Dcited before2026-04-29 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a properly sized mattress to meet the needs of a tall resident, resulting in the resident's foot extending beyond the mattress, affecting comfort and dignity. Findings Includes: R1 is a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses including but not limited to hypertension, peripheral vascular disease, hyperlipidemia, chronic kidney disease, paraplegia, neurogenic bladder status post suprapubic catheter, osteomyelitis status post right below-knee amputation, anemia, decubitus sacral ulcer, and colostomy. On the (MDS) Minimal Data Set assessment of 2/12/2026, section C, the BIMS (Brief Interviewed Mental Status) score was 15/15, indicating cognitive intact. On MDS of 2/12/2026, GG section R1 is dependent for personal hygiene and toileting hygiene. The helper does all the effort. The resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to meet the resident's need to have two staff members assist while being provided with incontinence care, as per the resident's assessed needs. This failure applied to one (R1) of three residents reviewed for falls and resulted in R1 sustaining a fall while being provided incontinence care that resulted in a left knee skin tear and right shoulder pain.Findings Includes:R1 is a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses including but not limited to hypertension, peripheral vascular disease, hyperlipidemia, chronic kidney disease, paraplegia, neurogenic bladder status post suprapubic catheter, osteomyelitis status post right below-knee amputation, anemia, decubitus sacral ulcer, and colostomy. On the (MDS) Minimal Data Set assessment of 2/12/2026, section C, the BIMS (Brief Interviewed Mental Status) score was 15/15, indicating cognitive intact. On MDS of 2/12/2026, GG section: R1 is dependent on personal hygiene and toileting…

  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 before2026-04-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide adequate supervision and implement appropriate interventions for one (R1) of three sampled residents reviewed for accidents and supervision who had severe cognitive impairment and was assessed as high risk for elopement. This failure resulted in R1 being sent to an outside medical appointment without an escort, leaving the medical building unsupervised, and being found confused and wandering in the street. Findings include:R1 is a [AGE] year-old, male, originally admitted in the facility on 11/11/25 with the following diagnoses: Encephalopathy, Unspecified; and Dementia in other Diseases Classified Elsewhere Moderate, with Agitation.MDS (Minimum Data Set) dated 02/10/26 documented R1's BIMS (Brief Interview for Mental Status) score of 5, which means severe cognitive impairment. MDS indicated R1 has no impairments on the upper and lower extremities. R1 is ambulatory with no assistive devices.On 04/20/26 at 10:43 AM, R1 was observed walking in…

  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 before2025-12-30 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care 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 physician order in using oxygen for resident who has respiratory disorder. This deficiency affects two (R2 and R3) of three residents reviewed for Respiratory/oxygen management.Findings include:1. On 12/26/25 at 10:34AM, Observed R2 sitting in wheelchair in his room with nasal cannula oxygen tubing in his mouth. R2 said he got tired of putting oxygen in his nose, so he put it in his mouth. R2 added that he still received the same oxygen. R2 is alert, oriented and response appropriately. R2 can verbalize his needs to staff. R2 had a long oxygen tubing from the oxygen concentrator at 3LPM (liters per minute) with no label or date of changed. R2 said they seldom changed his oxygen tubing. His oxygen concentrator was set at 3LPM, while his oxygen tank at the back of his wheelchair was set at 5LPM. V3 Nursing supervisor said R2's oxygen tank is almost empty but still okay. V3 added r2 usually asked the staff if his oxygen tank needs to be…

  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 · F2025-12-12 · tag F0804 — failed to serve food at safe, palatable temperature — widespread
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  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 residents were served meals at a safe, appetizing temperature by not checking the food temperature before serving. This applies to all 121 residents consuming food through the dietary service.The Findings include:On 12/09/2025 at 11:05 AM, during kitchen tray line observation, observed V20 (Dietary Aide) and V13 (Dietary Cook) started serving lunch from the kitchen steam table without checking the food temperature.On 12/09/25 at 11:20 AM, V13 stated, The old management never did that, and that's why I didn't check the food temp.12/09/25 at 11:25 AM, V14 (Dietary Manager) stated, I thought my cook (V13) checked the food temperature. We are supposed to check the food temperature before starting to serve.12/10/2025 11:00 AM V14 added, We took over this place in October. We don't have any documentation available to prove that we were checking the food temps.The facility presented the Policy and Procedure Manual, chapter 3, page 35, document: Record food temperature prior to service and again after…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-12-12 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to follow their Medication Storage, Labeling, and Disposal Policy. The facility failed to ensure medications will be stored in locked storage area. This failure has the capacity to affect 19 residents (reviewed for medications) in a total sample of 29. On 12/09/2025 at 12:08 PM, during rounds on the unit, observed medication cart in unit A, first floor, to be unlocked, third drawer opened halfway, with no authorized staff in the hallway. The medication cart was facing in the opposite direction that V7 (Registered Nurse/RN) was in.On 12/09/2025 at 12:12 PM, V7 (Registered Nurse) walked out of a resident's room, noticed the cart was left unlocked and third drawer open, proceeded to turn the cart the opposite direction. V7 (RN) stated the medication cart should have been fully closed and locked, for safety. On12/10/2025 at 10:23 AM, V8 (Assistant Director of Nursing/ADON) stated it is important for nurses to make sure the medication carts are closed and locked when a nurse walks away from the medication cart 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-12 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
  Reasonably accommodate the needs and preferences of each resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to follow their Call Light Policy. The facility failed to ensure call lights are placed within reach of residents who are able to use it at all times. This deficient practice affects 2 residents (R68 and R52) of 4 residents reviewed for accommodation of needs in a total sample of 29 residents.On 12/09/2025 at 8:13AM Observed R68 and R52 in the same room, each asleep in their assigned beds. The privacy curtain was fully extended out in between R68 and R52. Observed R68's call light attached and clipped high, in the middle of the curtain that was extended all the way to R68's foot bed frame, not within reach of R68. R52's call light was observed under R52's bed, on the floor close to the foot of the bed, not visible to R52. Both R68 and R52's call light string was attached and connected to the call light system. R68s Minimum Data Set (MDS) has a Brief Interview for Mental Status (BIMS) of 15/15, Cognitive intact.R52s Minimum Data Set (MDS) has a Brief Interview for Mental Status (BIMS) of 10/15, cognitive…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-12 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to follow their abuse policy by not protecting a resident from employee-to-resident abuse. This failure resulted in R85 sustaining redness, mild swelling, and facial bruising. This affected 1 resident of 3 reviewed for (Employee-to-Resident) Abuse in a total sample of 29.Findings include:On 12-9-25 at 8:26 AM R85 was observed with a resolving facial bruise below his right eye. R85 said 2 weeks ago, V16 (unnamed Agency Certified Nurse Aide) punched R85 in the face. R85 said the V16 did not knock on the door and announce she is coming in the room. R85 said he does not remember V16's name nor did she announce herself. V16 told R85 she did not read the door signs or use the doorbell because R85's front door is too cluttered. R85 said V16 was tending to R85's roommate. R85 said he spilled his coffee and V16 was coming at R85 in an aggressive manner. R85 said he threw his coffee at V16. R85 said V16 punched R85 in the face with her left hand. R85 said he had blood from his face and refused to let the nurses tend 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-12 · 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 observation, interview and record review, the facility failed to ensure specialty mattress devices were on the correct weight setting for residents who are high risk in developing pressure injuries. This failure has the potential to affect two resident (R27 and R69)) out of three residents reviewed for pressure injury prevention and treatment in a final sample of 29 residents.Findings Include:R69:On 12/9/25 at 8:00AM, observed R69 in bed, asleep using specialized mattress. Low Air loss mattress is set to 4 (250 lbs.)On 12/9/25 ay 8:07AM, confirmed with V3 (Registered Nurse) R69's Low Air loss mattress is set to 4 (250 lbs.). V3 stated the Low Air loss mattress has a sticker on it to let V3 know which number setting the resident needs. V3 stated that the supervisor is the one that updates the sticker. The mattress setting should be within the resident weights.R69 is [AGE] year-old female with diagnosis of but not limited to type 2 diabetes, vascular dementia, osteoarthritis, peripheral vascular disease,…

  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.

“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.

Fines & penalties

$223,481 in federal fines across 5 penalties. 3 Medicare payment denials on record.

• $14,785 — penalty dated 2025-04-01
• $53,980 — penalty dated 2025-03-14
• $14,803 — penalty dated 2024-12-26
• $88,413 — penalty dated 2024-05-02
• $51,500 — penalty dated 2024-01-21
• Medicare payment denial — starting 2025-04-12 for 1 days
• Medicare payment denial — starting 2024-05-25 for 32 days
• Medicare payment denial — starting 2024-02-16 for 31 days

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

Part of a chain

This home belongs to PRIME HEALTHCARE — 6 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 12 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

2 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 $2.1M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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, FY2024). 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