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Pearl Of Rolling Meadows,the

4225 Kirchoff Road, Rolling Meadows, IL 60008 · For profit - Individual · 155 certified beds · (847) 397-2400 Medicare & Medicaid certified

Call the home — (847) 397-2400 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0602) — most recent Dec 20242 actual-harm citations
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Dec 2024
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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

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

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1883 Hicks Rd · (847) 359-9437 · Call to confirm hours
Pharmacy
2045 Plum Grove Rd · (847) 303-2450 · Call to confirm hours
Grocery
2122 Plum Grove Rd · (847) 221-8468 · Call to confirm hours
Park
4360 Euclid Ave · (847) 818-3220 · Typically dawn to dusk
Place of worship
4242 Kirchoff Rd · (847) 934-4223

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 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 3 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 held steady at 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased6.7%13.4%15.4%better
Long-stay residents who lose too much weight2.6%6.3%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.9%0.9%better
Long-stay residents with a urinary tract infection0.2%1.5%2.0%better
Long-stay residents with depressive symptoms95.6%54.2%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.7%3.1%3.3%typical
Long-stay residents whose ability to walk worsened8.1%14.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication13.7%18.3%18.9%better
Long-stay residents given the seasonal flu vaccine94.3%91.8%95.3%typical
Long-stay residents with pressure ulcers3.1%4.8%4.7%better
Long-stay residents with worsening bladder/bowel control8.5%20.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table28.5%21.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication3.1%2.2%1.4%worse
Short-stay residents given the seasonal flu vaccine9.2%63.1%79.4%worse
Short-stay residents rehospitalized after admission22.2%26.1%22.6%typical
Short-stay residents with an outpatient ER visit10.4%13.9%12.0%better
Long-stay hospitalizations per 1,000 resident days2.132.021.67worse
Long-stay outpatient ER visits per 1,000 resident days0.682.221.80better

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.

47.3% 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 109 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

47.3%U.S. median 51.5%
Got home and stayed home
11.0%U.S. median 10.7%
Went back to hospital
59.2%U.S. median 56.6%
Met the expected recovery
0.27U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

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 49 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 0.27 therapist hours per resident per day in 2026Q1 — more than 40% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 18% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF47.3%CMS range 40.0–56.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.0%CMS range 7.9–14.610.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge59.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge49.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge49.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified98.9%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.3%CMS range 3.7–9.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.391.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.85
RN hours/ resident / day
0.64
LPN hours/ resident / day
1.84
Aide hours/ resident / day
3.33
Total nurse hours/ resident / day
0.66
RN hoursweekends
36.5%
Total nursing turnover
40.7%
RN turnover

How full it usually is: this home is certified for 155 beds and averages 120.6 residents a day — about 78% occupied, or roughly 34 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.33 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.85 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.84 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 2.87 hrs/resident/day on weekends vs 3.52 on weekdays — 19% thinner on weekends. RN hours go from 0.92 to 0.66 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 36% 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

5
deficiencies at the latest standard inspection (2025-03-27)
5
at the previous standard inspection (2024-02-09)

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.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

29 citations, most serious first. The 12 most serious are shown; the remaining 17 are one tap away and print in full.

  • Actual harm · Gcited before2025-03-27 · 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 observations, interviews, and record reviews, the facility failed to provide adequate supervision for residents at high risk for falls and failed to implementing interventions for a resident with wandering behaviors. These failure applied to three of five residents (R52, R56, and R61) reviewed for falls and resulted in R52 sustaining a right hip fracture and a head injury requiring medical treatment. Findings include: Per the facility's incident log from 09/01/2024 - 03/24/2025 the facility has had 73 unwitnessed falls with 18 of them involving memory care residents, R52 had a fall each month from December 2024 - March 2025 with two of them being unwitnessed, and R61 had four falls within three weeks of admission with three of them being unwitnessed. 1. R52 is a [AGE] year-old female with a diagnosis history of Dementia with Behavioral Disturbance, Anxiety Disorder, Age Related Cataracts, and Stroke who was admitted to the facility 02/06/2019. The facility's incident log from 09/01/2024 - 03/24/2025…

    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 before2024-08-01 · 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 properly monitor/supervise a high fall risk resident and ensure safety during incontinence care. This affected one of three (R2) residents reviewed for safety during care. This failure resulted in R2 rolling out of bed suffering a laceration to the head which required six sutures at the hospital. Findings Include: R2 is a [AGE] year old with the following diagnosis: malignant neoplasm of the stomach, dementia, anxiety disorder, and repeated falls. An Incident note dated 6/5/24 documents the CNA (V10 - Former CNA) called the nurse's attention to R2's room. R2 was observed lying on R2's left side on the floor with a red substance noted on the floor. R2 stated that R2 rolled out of bed. Pressure was applied to the head by wrapping with gauze to stop the bleeding. 911 was called. The Hospital Records dated 6/5/24 document R2 presented to the emergency department with a fall. R2 reportedly was reaching for an item and fell off the bed, striking the left…

    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 · D2026-04-10 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure signed consents for the use of psychotropic medications (a drug which affects behavior, mood, thoughts, or perception) were obtained from the resident's representative related to the risks and benefits of using psychotropic medications for one of one resident (R2) reviewed for psychotropic medication use. Findings include:On 4/9/2026 at 11:30am this writer reviewed, R2 Physician Orders dated 1/8/2026 Quetiapine Fumarate 25mg, give 0.5 tablet by mouth three times a day for behavioral disturbances and on 1/25/2026 Quetiapine Fumarate 25mg give 12.5mg by mouth STAT for agitation one time only.On 4/9/2026 at 12:30pm V4(Nurse) said I spoke with the Nurse Practitioner concerning R2 behaviors, an increase in R2 psychiatric medication was ordered, I did not obtain a consent, If the nurses take an order for antipsychotic medication, then the nurses should obtain the consent moving forward I will do so.On 4/9/2026 at 1:50pm V2(Director of Nursing-DON) said I expect when a nurse obtains an order for a psychiatric 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.

    Resident Rights Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · Dcited before2026-04-10 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record reviews, the facility failed to ensure medication were administered as ordered by a Physician for one of three residents (R1) reviewed for medication administration. Findings Include:On 4/7/2026 at 11:40am R1said that she does not receive her medication at 6am and that medication help to balance her thyroid.On 4/7/2026 at 2:00pm this writer reviewed R1 electronic medication administration record indicating that on 3/5/2026, 3/28/2026 and 4/3/2026 at 6am levothyroxine sodium 125mcg. did not have a signature. On 4/9/2026 at 1:00pm V9(Nurse) said I did not work on those days, I think I would have signed them out or maybe I forgot to sign them out.On 4/9/2026 at 1:45pm V2 (Director of Nursing-DON) said I expect the nurses to sign out all medications if it is not signed it was not given.An order summary written on 6/25/2025 Levothyroxine sodium oral tablet 125mcg give 1 tablet by mouth one time a day related to unspecified hypothyroidism. A care plan focus of at risk for manifestations of hypothyroidism AEB, an intervention to administer hypothyroidism…

    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 · E2025-12-19 · tag F0926 — failed to keep the home smoke-free / fire-safe — pattern
    Have policies on smoking.
    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 implement its smoke policy by allowing residents to smoke near the main entry door and not having metal containers with self-closing cover devices in smoking areas. This applies to all four smokers (R1, R2, R3, and R4) reviewed for safe smoking in a sample of 4.The findings include:On 12/19/25 at 9:12 AM, V2 (Director of Nursing/DON) stated that we have four smokers (R1, R2, R3, and R4) in the building, and our designated smoke area is on the left side of the building (50 to 60 feet away from the main entry door) with benches.R1 is a [AGE] year-old male with intact cognition as per the Minimum Data Set (MDS). On 12/19/25 at 9:15 AM, observed R1 coming from the left side of the building after smoking. R1 stated, I pretty much smoke here on the left side of the building. Sometimes I go to the right side of the building to smoke.On 12/19/25 at 9:15 AM, observed the designated smoke area with V2 and observed cigarette butts on the ground with…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-26 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    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 revise and update the comprehensive care plan for one resident identified with injury of unknown origin. This deficiency has the potential to affect 1 of 3 residents (R1) reviewed for Injury of Unknown Origin in a sample of 3. Findings Include:R1 admitted to facility on 11/6/2018. Diagnosis information includes senile degeneration of brain, Alzheimer's disease, primary generalized osteoarthritis, vascular dementia. On 11/25/2025 at 10:43AM, R1 in the second-floor dining room, seated on the wheelchair with pillow on her back and no protective (geri) sleeves worn was observed.Review of Illinois Department of Public Health (IDPH) final report, date 8/25/2025, State Report indicate R1's intervention include staff to place pillows on her sides when up on wheelchair, to provide additional support or cushion when leaning on hard surface. Will provide Gerisleeves to both arms. Review of comprehensive care plan report did not indicate the occurrence and revision/updated interventions of R1's injury of unknown origin…

    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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-13 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to notify the local emergency room hospital of a resident's transfer for 1 of 1 resident (R1) reviewed for admission, transfer and discharge. Findings include:On 8/12/2025 at 11:30am V4(Nurse) said that R1 had an unwitnessed fall and was found on the bedroom floor with a pillow under his head, V4 said that R1 is alert and oriented times one and unable to say what happened R1 was assisted to the bed and the nurse practitioner gave orders to send to the local emergency room for an evaluation. V4 said that she gave report to the oncoming nurse of the incident, prepared documents, while R1 was waiting for the ambulance to arrive, V4 said she did not notify the local emergency room hospital of R1 transfer because she did not know when the ambulance would arrive, V6(Nurse) expressed understanding. On 8/12/2025 at 1:00pm V6(Nurse) said that he received report from the ongoing nurse of R1 fall and that R1 is alert but confused and would not be able to say what happened to him. V6 said when the ambulance arrived, he gave documents 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 · E2025-03-27 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that staff provide shower and grooming for residents who are dependent on staff for Activities of Daily Living (ADL). This failure affected four (R16, R24, R28, and R86) of five residents reviewed for ADL care. Findings include: R24 is [AGE] years old and has resided at the facility since 2016, past medical history includes hemiplegia and hemiparesis following nontraumatic intracranial hemorrhage affecting right dominant side, chronic obstructive pulmonary disease, chronic kidney disease stage 1, pain in left leg, etc. On 03/24/25 10:20AM, R24 was observed in her room, awake and alert and stated that she has been at the facility for a while, R24 said that she has issue with showers because it seems like they do not have enough people to do the showers. R24 said that she does not receive her showers two times a week as scheduled. Resident stated that she does not have any wounds that she is aware of, but her bottom feels raw, 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 · E2025-03-27 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    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 interview and record review, the facility failed to provide residents with palatable and attractive food. This failure affected 13 of 13 residents (R20, R24, R28, R38, R32, R84, R70, R41, R117, R126, R69, R78, and R35) reviewed for dining. Findings include: On 3/24/2025 at 10:17AM, R20 said that the food is very bad, she does not eat anything from the facility and has to order food from outside all the time. At 10:20AM, R24 said the food is not good and they do not really have a lot of alternatives to choose from. At 10:45AM, R28 said she does not like the food and has her family bring her food from outside. At 10:50AM, R38 said the food is not good. At 10:54AM, R32 stated he hasn't had a warm breakfast in months. At 11:15AM, R84 and R70 said the food is always cold. At 11:35AM, R41 said the food is horrible. I have to have my family grocery shop for me, and I eat what I have in my refrigerator. It is to be noted that R41 had her own refrigerator in her room with multiple various food items for meals and dry storage goods stored. At 11:40AM, R117 said the good is very poor…

    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 · D2025-03-27 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that staff provide incontinence care in a timely manner for a resident assessed as dependent on staff for Activities of Daily Living (ADL). This failure affected one (R24) of one resident reviewed for incontinence care. Findings include: R24 is [AGE] years old and have resided at the facility since 2016, past medical history includes hemiplegia and hemiparesis following nontraumatic intracranial hemorrhage affecting right dominant side, chronic obstructive pulmonary disease, chronic kidney disease stage 1, pain in left leg, etc. On 03/24/25 at 10:20AM, R24 was observed in her room, awake and alert and stated that she has been at the facility for a while, she has issue with showers because it seems like they do not have enough people to do the showers. R24 said that she has not been changed today and have been waiting to be changed. R24 said that she is very wet right now, she was not changed during the night shift, the last time…

    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 before2025-03-27 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to follow facility medication administration policy of ensuring that staff document the administer narcotic medications in the narcotic count sheet, and failed to ensure that the narcotic medications are properly reconciled by staff. These failures affected three (R39, R43 and R70) of five residents reviewed for psychotropic medications and have the potential to affect residents in the North wing, TCU, and memory care units of the facility. Findings include: R39 is [AGE] years old and has resided at the facility since 2026, past medical history includes, but not limited to malignant neoplasm of unspecified kidney, except renal pelvis, chronic pancreatitis, unspecified dementia, type 2 diabetes, anemia, etc. Physician order dated 6/7/2024 showed the following: Morphine Sulfate (Concentrate) Solution 20 MG/ML *Controlled Drug* Give 0.25 ml sublingually every 2 hours as needed for pain; sob. 03/25/25 11:15AM, reviewed the standard even…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-14 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to provide Quality of Care/Treatment related to clinical management of Urinary Tract Infection (UTI) affecting 1 of 4 (R3) residents reviewed for Quality of Care/Treatment. Findings Include: On 3/11/2025 at 11:05 AM V3 (Assistant Director of Nursing/IP) stated on 1/13/2025, he received an order from V18 (Nurse Practitioner) to start R3 with antibiotic Bactrim twice a day for 3 days. V3 stated he entered the order into the electronic medication administration (EMAR) to reflect first dose in 1800 to be administered by nurse on duty. Bactrim antibiotic was ordered STAT from Pharmacy and delivered on 1/14/2025 at 12:31AM to facility. V3 stated first dose of antibiotic can be obtained in the facility convenience box (also known as pixes, capsca). V16 (Licensed Practical Nurse/LPN) nurse to give the first dose acknowledged she did not give the Bactrim as ordered on 1/13 at 1800 to R3. V13 (Licensed Practical Nurse), AM shift nurse on 1/14/25, verbally stated she gave the antibiotic Bactrim on 1/14/2025 at 0900 but acknowledged not…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · D2024-12-20 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident was free from physical abuse to 1 of 9 resident (R4) reviewed for physical abuse in the sample of 9. The finding include: R4's face sheet show R4 79 y/o that has diagnoses that includes dementia, wanderer, restlessness and agitation. R4's facility assessment dated [DATE] show R4 is severely cognitively impaired. The same assessment under section E (Behavioral Symptoms and frequency) show: [R4 has] Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others .) behavior of this type occurred 1-3 days Wandering . behavior of this type occurred 4-6 days R4's careplan with initiated date of 6/10/24 shows, R4 exhibits physically aggressive behaviors. R/t: cognitive deficit, dx of dementia, poor comprehension. Resident becomes combative unprovoked. He has bitten a staff members arm that required medical attention. He has grabbed a CNA who was trying to change him causing 2 broken…

    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 · D2024-12-20 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to return a resident's personal belongings after discharge from the facility for 1 of 3 residents (R1) reviewed for misappropriation of property in the sample of 9 . The findings include: R1's EMR (Electronic Medical Record) shows that R1 discharged from the facility on 10/10/24 after calling 911 for himself, going to the hospital and being admitted to another facility. On 12/20/24 at 9:45 AM V5 (Social Service Director) stated, He went to another facility and I think he has transferred to another facility since then. Someone came from the other facility and picked up his mail and a store brand box (mail item.) He has called several times about his belongings- everything we had was in my office and that was just his mail. The only thing I know he had in his room was a lot of books. He had different shirts on while he was here so I know he had clothes. He was given the opportunity to come pick up his stuff. I had several phone calls with him and would say he is coming on Tuesday and then it would be Thursday. I even called…

    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 before2024-12-20 · 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, record review the facility failed to ensure the prescribed treatment was performed for a resident's surgical wound and failed to ensure medical information was sent with a resident's surgical follow up appointment. This applies to 1 of 3 residents (R2) reviewed for quality of care in the sample of 9. The findings include: R2's face sheet shows he was a [AGE] year old male with diagnoses including orthopedic aftercare following surgical amputation, acute hematogenous osteomyelitis left foot and ankle, cellulitis of left lower limb, complete traumatic amputation of one left toe, type 2 diabetes with foot ulcer, diabetic neuropathy, congestive heart failure, heart disease, dependence of renal dialysis, non-pressure of chronic ulcer of left foot with necrosis of muscle, and occlusion and stenosis of bilateral cardiac arteries. On 12/20/24 at 10:41 AM, V14 (ADON) said residents who are sent out on appointments should be sent with the face sheet, physician orders, and labs. This is the way we…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-28 · 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

    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 enough bath towels. This failure affected two of two (R1, R2) residents reviewed for supplies. Findings include: 1. R1 is a [AGE] year-old female originally admitted on [DATE], with medical diagnoses that include and are not limited to: chronic obstructive pulmonary disease, radiculopathy sacral, and sacrococcygeal region and anemia. On 10-26-2024 at 11:00am, R1 said, The big problem that I have encountered here since I came in December 2023 is the lack of supplies. I need to wait for the staff to give me the shower supplies such as towels, soap, and a gown. Many times I need to ask many times before I get the supplies because we do not have available towels; they only bring a few towels that the staff take for the patients that are in the bed. I saw you going into the linen room; as you can see it is empty. That makes me feel very unhappy and sad. I do not like to have a bad body odor. I cannot take a…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-06-12 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
    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 ensure call light cords were within reach for 4 residents (R6, R7, R8, and R9) out of 9 residents reviewed for call light accessibility. Findings include: 1. R7's call light ability screen, dated 5/22/24, notes R7 is able to use the call light. On 6/10/24 at 11:00 AM, R7 was observed lying in bed. There was no call light cord observed near R7's bed. On 6/10/24 at 11:05 AM, V3, RN (Registered Nurse) was unable to locate R7's call light cord. After searching R7's room, V3 found R7's call light cord under the blanket of R7's roommate's bed. V3 stated R7's call light cord should be within reach of R7. 2. R8's call light ability screen, dated 5/16/24, notes R8 is able to use the call light. On 6/10/24 at 11:10 AM, R8 was observed lying in bed. R8's call light cord was observed between R8's mattress and bed frame. R8's call light cord was not within reach. 3. R9's call light ability screen, dated 5/15/24, notes R9 is able to use the call light. On 6/10/24 at 11:13 AM, R9 was observed lying in bed. R9's call light…

    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 · Fcited before2024-02-09 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure facility kitchen staff are wearing hair restraints (e.g., hairnet, hat and/or beard restraint) while preparing food to prevent hair from contacting food. This deficiency has potential to affect 127 residents who consumes meal from the kitchen. Findings include: On 02/06/24 at 10:05 AM, During initial round in the kitchen, V10, Dietary Director (DD), and V27, Cook, did not have a hair restraint. V27 was in the process of preparing food and cutting off ham meat. V27 was wearing a hairnet, and hair was exposed while preparing food. V10 came into the kitchen just wearing a hat with exposed long hair and beard, but no restraint. Rounded the kitchen with V10 who was not wearing hair restraint. On 02/07/24 at 10:10 AM, V10, DD, was wearing a hat with exposed long hair while cutting the carrots. V10 said he's wearing a hat. Surveyor asked if he is aware his hair is not fully restrained with just the hat on. V10 shrugged his shoulders On 02/07/24 at 10:15 AM, V1, Administrator, said kitchen staff should wear a…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-02-09 · 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 keep the controlled substance medications in the refrigerator per pharmaceutical/manufacturer's recommendation. This deficiency affects four (R36, R41, R97 and R98) of four residents reviewed for Medication Storage. Findings include: On 2/6/24 at 11:14AM, Checked narcotic medications in medication cart with V14, LPN (Licensed Practical Nurse). Observed the following medications with pharmaceutical instruction to store in refrigerator as written in medication container. V14 said those medications- morphine and lorazepam liquids should be kept in the refrigerator after administration. V14 said they should follow pharmaceutical recommendation. The following medications were found: 1)R41's Morphine sulfate 20mg /ml solution ( 5ml), left 4.25ml and Lorazepam 2mg/ml oral solution ( 5ml ), left 4.5ml. 2)R36's Morphine sulfate solution 20mg/ml ( 5ml), left 4.5ml. 3)R97's Morphine sulfate 20mg /ml ( 30ml) unopened; Morphine sulfate 20mg/ml ( 5ml), left 1.75ml and Lorazepam 2mg/ml( 5ml), left 2ml. 4)R98's Morphine…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the resident's environment is free from accident hazards and each resident receives adequate supervision to prevent accidents for 1 of 3 residents (R35) in a sample of 27 residents reviewed for medication safety. Findings include: admission Record indicated R35 has a diagnosis of End Stage Renal Disease and Dependence on Renal Dialysis. An Order Summary Report indicated Sevelamer Carbonate Oral Tablet. Give 1 tablet by mouth with meals related to End Stage Renal Disease. On 02/06/24 at 12:34 PM, R35 had medication at bedside, which had not been consumed. R35 said it is her medication for dialysis that she takes with meals. No food or meal tray was seen at this time. R35 said it is their practice to leave such medication, and assume for her to take it when her food arrives. On 02/06/24 at 12:39 PM, V17 (License Practical Nurse -LPN) said medication should be given when food arrives, and medication should not be left at bedside. V17 identified the medication as dialysis medication, Sevelamer. On 02/06/24…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-09 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to check for GT (gastrostomy tube) placement prior to administration of medication and enteral feeding. This deficiency affects one (R71) of one resident in the sample of 27 reviewed for tube feeding management. Findings include: R71 was re-admitted on [DATE], with diagnoses listed in part but not limited to Dysphagia, Gastrostomy, and Encephalopathy. Physician order sheet indicates: Glucerna 1.2 150 ml every 4 hours. Flush with 120ml water every 6 hours. Flush enteral tube with 30ml water pre/post medication administration and 5-10ml water between each medication. On 2/6/24 at 3:35PM, V20, LPN (Licensed Practical Nurse), prepared R71's medication. V20 mixed and crushed medication with 5ml water in a medicine cup. V20 prepared 2 medicine cups and placed 5 ml of water each. R71 was lying in semi-sitting position. V20 took the GT 60ml syringe and removed the plunger. V20 connected the syringe into R71's gastric tube and poured the 5ml water…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-09 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to disinfect/sanitize medical equipment (digital blood pressure monitor and pulse oximeter) used after each resident during medication administration. This deficiency affects two (R86 and R112) of six residents in the sample of 27 reviewed for Infection control. Findings include: On 2/6/24 at 10:17AM, V13, Registered Nurse (RN), took the digital blood pressure monitor from the medication cart and placed it on R112's left upper arm. V13 placed the pulse oximeter on R112's left index finger. V13 scanned R112's forehead to check for her body temperature. After taking vital signs, V13 placed all the medical equipment used on top of the medication cart without disinfecting/sanitizing them. V13 prepared scheduled medications and administered to R112. On 2/6/24 at 10:27AM, V13, RN, took the vital signs equipment (digital BP monitor, Pulse oximeter and thermometer) from the medication cart, without disinfecting it. V13 placed the digital BP monitor on R86's left upper arm. V13 placed pulse oximeter on left middle…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement and develop fall preventive interventions to residents who are at risk for falls. This deficiency affects all four (R1, R2, R3 and R4) residents reviewed for Fall Prevention Management. Findings include: 1. R3 is admitted on [DATE], with diagnosis listed in part but not limited to Traumatic Subarachnoid Hemorrhage, fall encounter, Abnormalities of gait and mobility, Need assistance with personal care, Dementia, Psychosis. Fall admission assessment indicated at high risk for fall. Care plan indicates she is at high risk for fall due to poor safety awareness related to cognitive impairment, Gait/ imbalance problems, use if psychotropic medications. Intervention: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to call request for assistance. The resident has had an actual fall on 10/2/23 Laceration to the right temple with 3 staples,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-27 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    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 diet ordered by the physician. This deficiency affects one (R2) of three residents reviewed for Therapeutic diets prescribed by physician. Findings include: On 10/25/23 at 9:40AM, R2 had just finished eating breakfast. Her dietary card indicated she is on Consistent Carbohydrate (CCHO) NAS (No added Salt). R2 was readmitted on [DATE], with diagnosis listed in part but not limited to Acute cholecystitis, Esophagitis, Gastroesophageal Reflux, Type 2 Diabetes Mellitus. Physician order sheet indicates: Mechanical soft, low fiber regular diet. R2 was not evaluated by Dietitian upon readmission from hospital. On 10/25/23 at 1:10PM, V25, Registered Dietitian, said she comes to the facility weekly to evaluate newly admitted or readmitted residents for appropriate diet. She said she has not seen or evaluated R2 since she was readmitted on [DATE]. She said they should follow physician diet ordered. Facility's policy on Nutritional assessment…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-12-16 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and, record review, facility to follow their policy to ensure all dry foods and frozen foods are labeled and dated, and failed to ensure all pots are washed, sanitized and air dried. These failures have the potential to affect 115 residents in the facility. Findings include: On 12/13/2022 at 9:30 AM, surveyor observed cereal bins, hamburger buns, and hotdog buns in the dry storage room that were out of initial boxes, and not labeled or dated. On 12/13/2022 at 9:45 AM, surveyor observed chicken, hotdogs, sausage meats, and waffles not dated in the freezer. On 12/13/2022 at 9:46 AM, surveyor observed ham that was not kept in the freezer, soft and not dated. On 12/13/2022 at 11:00 AM, surveyor observed V7 (Corporate cook) use the puree machine to puree lasagna. After the lasagna was pureed, V7 washed the food pot in the sink and immediately, without drying, V7 brought the food pot back to the puree machine to puree vegetables. V7 then pureed the vegetables. Surveyor observed some lasagna residual in the pot. On 12/14/22 at 10:22 AM, V8 (Dietary Manager)…

    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 · Ecited before2022-12-16 · 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: 1. label opened inhalers, multidose vials of Insulin and nasal sprays with open and discard dates used by residents and stored in 4 of 4 carts in a sample of 7 carts reviewed for medication storage; 2. ensure no food items are kept inside the medication refrigerator; 3. ensure narcotics are counted at the beginning and end of each shift; 3. discard medications of expired and discharged residents; and 3. ensure medication cart is secure. These failures affect 27 residents (R88, R11, R31, R46, R86, R38, R22, R78, R68, R83, R6, R75, R35, R9, R99, R371, R369, R370, R372, R2, R373, R97, R111, R55, R30, R91, and R16) and have the potential to affect all 89 residents who reside in the 1st and 2nd floor of the facility. Findings include: On 12/13/22 10:49 AM, with V3, Registered Nurse, the following were observed on the 1st floor Medicare Cart 2: *R41's open Albuterol Sulfate HFA 90 mcg 8.5 gram inhaler has no label for open and discard date V3 stated, Once you open it, it should be labeled on when it was opened. 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-16 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, observation, and record review, the facility failed to follow recommended dietary interventions and physician order for one resident (R33) in a sample of 24 residents reviewed for nutrition. Findings include: R33's nutrition/dietary progress note, dated 6/30/2021, reads in part: Recom (Recommendation): Add ½ PB (peanut butter) and Jelly sandwich with every dinner meal and vanilla or berry flavored (nutritional supplement) with every lunch meal for encouraged adequate nutrition and wt (weight) maint (maintenance). R33's nutrition/dietary progress note, dated 9/29/2021, reads in part: Recom: Increase ½ PB and Jelly sandwich to BID (twice daily) with every lunch and dinner meal for encouraged adequate nutrition and wt maint. R33's physician order summary reads in part: Start date, 6/21/2022, Enhanced diet mechanical soft texture, regular consistency, ADD ½ PB&J (peanut butter and jelly) sandwich with every lunch and dinner meal; ADD vanilla or berry flavored (nutritional supplement) with every lunch meal. On 12/13/2022, surveyor observed R33's lunch meal. There was…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-12-16 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure the timely reordering of a routine medication, and failed to ensure the availability of routine medication to enable continuity of care for one (R97) resident. Findings include: R97's facesheet documents R97 has diagnoses not limited to chronic kidney disease stage 3, benign prostatic hyperplasia (BPH), type 2 diabetes mellitus, GERD, Anemia, Essential hypertension, gout, cerebral infarction R97's POS (Physician Order Sheet) documents the following order: start date- 11/03/2022 Tadalafil tablet 5mg- Give 5mg by mouth one time a day for BPH. R97's medication administration record documents medication is scheduled at 9:00am daily. On 12/13/2022 at 12:00 PM, R97 stated, I have not been receiving my medication that helps with my frequent urination. It's been a while since I've received it, and the facility keeps saying that they ordered it from the pharmacy, but the medication still has not arrived. On 12/13/2022 at 12:07 PM, V5 (Registered Nurse/RN) stated, There is a problem with (R97's) insurance and that's why…

    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 · D2022-12-16 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure a medication was administered as ordered by the residents physician for one (R97) resident out of sample of 24 residents reviewed. Findings Include: R97s' facesheet documents R97 has diagnoses not limited to: chronic kidney disease stage 3, benign prostatic hyperplasia (BPH), type 2 diabetes mellitus, GERD (Gastroesophageal Reflux Disease), Anemia, Essential hypertension, gout, and cerebral infarction. R97s' POS (Physician Order Sheet) documents the following order: start date- 11/03/2022 Tadalafil tablet 5mg- Give 5mg by mouth one time a day for BPH. R97s' medication administration record documents medication is scheduled at 9:00am daily. On 12/15/2022 at 11:07 AM, V25, Registered Nurse/RN stated, Yes, I am the nurse assigned to care for (R97) today. Yes (R97's) medication was received from pharmac,y but I did not administer (R97's) medication (identified as Tadalafil) today. V25 observed checking R97's electronic medication administration record and stated, (R97's) medication was scheduled 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

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

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to PEARL HEALTHCARE — 15 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.7+0.3 vs chain
Health inspection 3 of 52.7+0.3 vs chain
Staffing 3 of 52.1+0.9 vs chain
Quality measures 4 of 53.7+0.3 vs chain
The other 14 homes this chain runs (chain average 2.7★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
JOEZEE MEADOWS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST6%since 11/01/2018
KUSHNER FAMILY IDF LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST6%since 11/01/2018
REG 2018 IRREVOCABLE TRUST U/A/D 1/1/18Organization5% OR GREATER DIRECT OWNERSHIP INTEREST6%since 11/01/2018
HALBERSTAM, BENJAMINIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST5%since 11/01/2018
MAGENCE, MEYERIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST5%since 11/05/2018
ZEFFREN, EITANIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER60%since 11/01/2018
BERG, KATHRYNIndividualW-2 MANAGING EMPLOYEEsince 11/01/2018
SCHMIDT, MICHELEIndividualW-2 MANAGING EMPLOYEEsince 11/01/2018

CMS files one row per role, so the 9 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$14.4M
Net patient revenuemost recent cost report
-1.9%
Operating marginrevenue minus expenses
$784K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 76%Medicare 14%Other / private 11%

About 76% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $784K 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

$329per resident / day
operating cost
$10,016per month
≈ monthly operating cost
$323per day
avg. revenue, all payers

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

What families pay in IL

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.

Typical monthly cost in Illinois
$8,304/mo
Nursing home (semi-private)
$9,216/mo
Nursing home (private)
$6,219/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145350. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-27, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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