Encore Village
350 West Schaumburg Road, Schaumburg, IL 60194 · For profit - Limited Liability company · 169 certified beds · (847) 884-5000 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0602), cited Mar 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $25,454 in federal fines (most recent 2024-10-31)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 5 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 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 25.4% | 13.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.0% | 6.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.8% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 20.5% | 54.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.0% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 25.2% | 14.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 15.1% | 18.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 97.7% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.0% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 14.7% | 20.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 17.1% | 21.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.8% | 2.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 67.6% | 63.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 20.1% | 26.1% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 10.8% | 13.9% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 0.82 | 2.02 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.05 | 2.22 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
69.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 617 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 68.5% 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 327 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 0.65 therapist hours per resident per day in 2026Q1 — more than 90% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 46% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 69.5%CMS range 63.0–73.3 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.1%CMS range 8.1–12.2 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 68.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 60.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 71.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 99.7% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 96.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.2% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.2% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.8%CMS range 4.0–7.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.05 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 169 beds and averages 119.0 residents a day — about 70% occupied, or roughly 50 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 3.99 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.25 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.13 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 3.53 hrs/resident/day on weekends vs 4.18 on weekdays — 16% thinner on weekends. RN hours go from 1.38 to 0.93 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 41% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 12 most serious are shown; the remaining 14 are one tap away and print in full.
- Actual harm · Gcited before2024-11-20 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide 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 a newly admitted resident on tube feeding was weighed weekly. This failure resulted in R125 losing 16.8 pounds (11.4% weight loss) in 18 days. The facility failed to monitor weights, assess residents who have had a significant weight loss and implement interventions to prevent further weight loss. This failure resulted in R20 losing 12.6 pounds (7.67% weight loss) in 1 month and R231 losing 10.2 pounds (6.6% weight loss) in 13 days. This applies to 3 of 5 residents (R20, R125 and R231) reviewed for nutrition in the sample of 26. The findings include: 1. R125's Face Sheet shows that he admitted to the facility on [DATE] with diagnoses of: severe protein-calorie malnutrition, gastrostomy, dysphagia and parkinsonism. R125's Physician's Order Sheet (POS) printed on 11/20/24 shows an order dated 10/24/24 for, Weekly weights x 8 weeks . The POS shows orders for NPO (nothing by mouth) and an order for enteral feeding. R125's Nutritional…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2024-08-26 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 report adverse side effects immediately, failed to monitor the use of psychotropic medications, and failed to carry out the orders to hold medication for a resident showing signs of adverse effects of excessive drowsiness. This failure resulted in R1 being sent out to the hospital for evaluation for stroke like symptoms. This applies to 1 of 3 residents (R1) reviewed or unnecessary medications in the sample of 5. The findings include: R1's face sheet shows she is [AGE] year-old female with diagnosis including somnolence (excessive drowsiness 8/15/24), altered mental status (8/15/24), unspecified dementia with other behavioral disturbance, heart disease, delusional disorder, anxiety disorder, unspecified hearing loss, vascular dementia with psychotic disturbance, mood (affective) disorder, and glaucoma. R1's hospital Records dated 8/15/24 documents [AGE] year-old female with a history of vascular dementia and behavioral disturbances presents…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-10-14 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 its advance directive/life sustaining policy by not having power of attorney implemented for a resident. This applies to 1 of 3 (R1) residents reviewed for advance directives in a sample of 3.The findings include: R1 was an [AGE] year-old male admitted on [DATE] having moderate cognitive impairment as per the Minimum Data Set (MDS) dated [DATE] and with an admitting diagnosis including heart failure, atrial fibrillation, urinary retention, urinary tract infection (UTI), history of falling, and Benign Prostatic Hyperplasia. On 10/10/25 at 11:25 AM, V9 (Nurse Practitioner) stated, The daughter was making decision on R1. One-time R1 came back from the hospital, signing out Against Medical Advice (AMA) on Uber. The daughter said she was tired of him and asked why the facility couldn't call my fiance, who has the power of attorney. On 10/14/25 at 1:46 PM, V7 (Social Service) stated, I am not sure who was the power of attorney for R1. I will ask the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-20 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to reconcile a residents' (R1) discharge medications with current prescription orders prior to discharging the resident. This failure affected two of three residents (R1, R3) reviewed for medications in the sample of three and resulted in several of R3's medications being found within R1's accompanying medications after discharging home.The findings include: On 08/20/2025, review of R1's Discharge summary dated [DATE] showed no documentation under sections for medication list, medication reconciliation, or medication review. On 08/20/2025, review of grievance/concern forms showed a concern for R1 dated 08/13/2025 that indicated V7 reported a medication mix-up to V2 (DON). Family concern documentation provided by V2 indicated that V7 contacted the facility on 08/13/2025 (day after R1's discharge) to report two medication bottles not prescribed to the resident were found among [R1's] discharge belongings. Documentation then indicated during the discharge…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-24 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 a resident received their scheduled medication for 1 of 3 residents (R1) reviewed for pharmacy services in the sample of 3. The findings include: A facility assessment done on 6/7/24 indicated R1 was cognitively intact. On 6/24/25 at 10:25 AM, R1 said the facility ran out of her tramadol (pain medication) causing her to miss a dose. R1's Medication Administration Record (MAR) for June 2024 showed R1 was to get tramadol scheduled four times a day and as needed. The MAR showed on 6/11/24 the 12:00 PM dose of tramadol was not given and to see the Progress Notes. R1's Progress Note entered on 6/11/24 at 1:01 PM showed tramadol was not available and the pharmacy would be delivering more after 2:00 PM. The progress note did not indicate tramadol was retrieved from the medication tower. R1's tramadol Controlled Substance Proof of Use sheet dated 6/7/24 showed after the 6/10/24 8:30 PM dose of tramadol was given, zero remaining tramadol was on hand. The next tramadol Controlled Substance Proof of Use sheet was dated 6/11/24…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-12 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect 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 protect a resident from the misappropriation of resident property when a credit card was stolen from a resident's room for 1 of 2 residents (R2) reviewed for the misappropriation of resident property in the sample of 3. The findings include: The Final Incident Report dated 12/20/24 for R2 showed, Incident category: Resident misappropriation of property/theft. Summary of Incident: The resident is a long-term resident of the facility and is alert and oriented x 3 (person, time, & place); she is forgetful at times. On 12/17/24 the unit manager received an email from the police department detective. He was seeking assistance to identify a photo of the person within the email. The individual in the picture is presumed to be the individual who used the credit card of R2 at a store. The unit manager immediately reported to the interim administrator regarding the email received. The unit manager and ADON (Assistant Director of Nursing) reached out to POA (Power of Attorney), daughter of the resident. The POA stated that she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-12 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to report to the state surveying agency an allegation of misappropriation of resident property immediately, but not later than 24 hours when a credit card was stolen from a resident's room for 1 of 2 residents (R2) reviewed for the misappropriation of resident property in the sample of 3. The findings include: The Social Service Note dated 11/19/24 at 9:30 AM for R2 showed, the social worker spoke with resident's daughter (V10) regarding the stolen credit card. V10 shares that the credit card has been reported as stolen, and a police report has been filed. V10 shares that the credit card was located in the resident's phone wallet. V10 reports that charges were made on the credit card on 10/1/24. Social worker filed a concern form and endorsed to the administrator. The facility did not have an Initial Incident Report dated 11/19/24. On 3/11/24 at 11:03 AM, V9 (Social Services) stated, she reported to V2 (previous Administrator) that a resident's credit card was missing in October 2024 when V10 (R2's POA - Power of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-12 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to have evidence that an allegation of misappropriation of resident property was thoroughly investigated for 1 of 2 residents (R2) reviewed for the misappropriation of resident property in the sample of 3. The findings include: The facility's Initial Incident Report dated 12/17/24 for R2 showed, Incident category: Resident misappropriation of property/theft. Summary of incident: Today on 12/17/24 at approximately 2:15 PM, V5 (Registered Nurse/Unit Manager), reported receiving an email from the police asking for assistance in the case that was being investigated involving the resident, R2's stolen credit card. In the email there was an image of an individual at the store whom they believe was involved in the theft of the credit card. Investigation initiated and ongoing. The report was signed by V4 (Assistant Executive Director). The Final Incident Report dated 12/20/24 for R2 showed, Incident category: Resident misappropriation of property/theft. Summary of Incident: The resident is a long-term resident of the facility and is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-20 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably 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 a resident's legs were properly supported while sitting in her wheelchair for 1 of 26 residents (R57) reviewed for accommodation of need in the sample of 26. The findings include: R57's Face Sheet shows she has diagnoses of: history of venous thrombosis and embolism, back pain, scoliosis, osteoporosis, history of a fracture and left foot pain. R57's Vitals Summary Report shows that she is 60 inches tall. On 11/18/24 at 11:39 AM, R57 was sitting in her wheelchair in her room. R57's feet were hanging approximately 6 inches from the floor and R57 did not have any leg rests on her wheelchair. R57's legs were reddish purple in color. On 11/19/24 at 1:00 PM, R57 said that if she puts her feet on the bar of the tray table, she is comfortable but if her legs are just hanging, it is not very comfortable. R57 said that she is about five feet tall. On 11/19/24 at 1:42 PM, V20 (Therapy Director) said that for proper positioning in a wheelchair, a resident's feet should be either flat on the ground or placed on foot…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-20 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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's advanced directives were discussed and implemented upon admission for 1 of 26 residents (R282) reviewed for advanced directives in the sample of 26. The findings include: R282's Face Sheet shows that he admitted to the facility on [DATE]. The Face Sheet shows that his original admission was 4/8/22. R282's Electronic Medical Record (EMR) has a POLST (Physician Orders for Life Sustaining Treatment) Form that shows that R282 does not want resuscitation. This form was uploaded into R282's EMR on 10/21/2024. R282's Physician's Order Sheet Printed on 11/20/24 shows an order dated 11/15/24 for R282 to be a full code (attempt resuscitation). R282's EMR does not document that social services discussed R282's advanced directives with him or his power of attorney prior to 11/20/24. R282's Social Services Note dated 11/20/24 shows, Verified POLST Form with resident and spouse, both resident and spouse confirm request for DNR (Do 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.
- Potential for harm · Dcited before2024-11-20 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents who require staff assistance with ADLs (Activities of Daily Living) received showers/baths. This applies to 2 of 26 (R58, R39) residents reviewed for activities of daily living in the sample of 26. The findings include: 1. R58's face sheet shows she is a [AGE] year old female including Parkinson's disease, congestive heart failure, contracture of the right hand, osteoarthritis, history of falls, atrial flutter, chronic kidney disease, and gout. R58's Minimum Data Set assessment dated [DATE] shows she is cognitively intact, has no rejection of cares, and requires substantial/maximum assistance with showers/bathing. On 11/18/24 at 10:26 AM, R58 was sitting in her wheelchair in her room. Her right hand was clenched and and she had tremors to her left hand. She said she is supposed to get showers twice a week on Wednesday and Saturday on PM shift. She said the last time she had a shower was a couple of weeks ago, when she asks…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a gait belt was used during a transfer and failed to ensure interventions were added to a resident's plan of care after a fall to prevent additional falls for 2 of 26 residents (R39 and R110) reviewed for safety in the sample of 26. The findings include: 1. On 11/18/24 at 11:48 AM, V23, Certified Nursing Assistant (CNA) transferred R39 to the toilet using a gait belt. V23 removed the gait belt to provide care and change R39's shirt. After R39 used the toilet, V23 directed R39 to stand and hold onto the bar on the wall. V23 did not reapply the gait belt before directing R39 to stand up. While V23 was providing perineal care, R39 stated, I can't hold on much longer .I'm getting heavy. V23 then pulled up R39's incontinence brief and pants up and assisted her to sit back into her wheelchair. On 11/19/24 at 1:27 PM, V19 (CNA) said that gait belts should be used on all resident transfers for the resident's safety. R39's (Resident Care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 14 citations
- Potential for harm · D2024-11-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
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 resident was administered oxygen using a high flow nasal cannula for 1 of 6 residents (R281) reviewed for oxygen administration in the sample of 26. The findings include: R281's Physician's Order Sheet printed on 11/20/24 shows diagnoses of: dependence on supplemental oxygen, hypertension, chronic kidney disease, chest pain, acute respiratory failure with hypercapnia and hypoxia, pulmonary hypertension, pulmonary fibrosis, chronic obstructive pulmonary disease and myocardial infarction. R281's oxygen order dated 11/5/24 shows, Oxygen: 7 liters a. continuous . On 11/18/24 at 9:45 AM, R281 was sitting in his chair in his room with oxygen on. R281's oxygen tubing and cannula were clear and appeared to be regular flow oxygen cannula. R281's oxygen tubing was plugged into an oxygen concentrator set at 7 liters of oxygen. On 11/19/24 at 1:05 PM, R281 was sitting in his room with his oxygen on and had the same clear tubing. R281's oxygen concentrator was still set at 7 liters. On 11/19/24 at 2:24 PM, V21…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-20 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 the facility failed to ensure staff administered medications to a resident and not leave them on the bedside table. This applies to 1 of 26 residents (R15) reviewed for pharmacy services in the sample of 26. The findings include: R15's face sheet shows she is a [AGE] year old female with diagnoses including congestive heart failure (CHF), chronic pulmonary embolism, type 2 diabetes, asthma, chronic kidney disease, macular degeneration, dyshpagia, anxiety, peripheral vascular disease, hypertension, and GERD (Gastroesophageal reflux disease). On 11/18/24 at 10:20 AM, R15 was in her room sitting in her wheelchair. A cup of crushed medications in water were on her bedside table. R15 said those are my medications, the nurse crushes them because they are hard for me to swallow. At 10:35 AM, this surveyor left the room, R15's cup of medications remained at the bedside table. On 11/20/24 at 10:47 AM, V2 (Director of Nursing) said nursing should not leave medications at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-20 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a resident was free from a significant medication error. This applies to 1 of 26 residents (R58) reviewed for medications administration in the sample of 26. The findings include: R58's face sheet shows she is a [AGE] year old female including Parkinson's disease, congestive heart failure, contracture right hand, osteoarthritis, history of falls, atrial flutter, chronic kidney disease, and gout. On 11/18/24 at 10:26 AM, R58 was sitting in her wheelchair in her room. Her left hand was shaking. She said she takes Carbidopa a medication for her Parkinson's disease in the morning, and is suppose to get her 2nd dose at 11:00 AM and sometimes she doesn't get her medication till 2:00 PM. On 11/19/24 at 9:07 AM, R58 said yesterday she did not get her medication for her Parkinson's on time, it was late. On 11/20/24 at 10:47 AM, V2 (Director of Nursing) said nursing should follow the five rights when administering medication including the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-20 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure medications were securely stored for 1 of 26 residents (R121) reviewed for medication storage in the sample of 26. The findings include: On 11/19/24 at 10:41 AM, R121 was in his room sitting in a chair. On the bedside table was a fluticasone-salmeterol respiratory inhaler and an azelastine nasal decongestant spray. R121 said the medications are kept on the bedside table. R121's Order Summary Report printed on 11/19/24 showed an order for fluticasone-salmeterol inhaler to be given two times a day. The same document showed an order for azelastine nasal decongestant spray to be given two times a day. On 11/19/24 at 10:45 AM, V22 (Licensed Practical Nurse- LPN) said R121 keeps the inhaler and nasal spray on the bedside table. V22 said R121 needed to be reminded on how to use the medications. V22 explained that R121 will forget to hold his breath when using the inhaler. On 11/20/24 at 11:53 AM, V15 (LPN) said medications are not left in a resident's bedside table because medications needs to be secured. V15…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-20 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 staff failed to wash their hands and change their gloves to prevent the spread of infection and failed to ensure staff donned all applicable Personal Protective Equipment for a resident with Enhanced Barrier Precautions (EBP) for 2 of 26 residents (R20 and R12) reviewed for infection control in the sample of 26. The findings include: 1. On 11/18/24 at 10:27 AM, V9 and V10 (both Certified Nursing Assistants- CNAs) provided incontinence care to R20. R20 had a bowel movement. V10 provided incontinence care to R20. Wearing the same soiled gloves and without washing her hands, V10 applied a new incontinent pad, turned R20 side to side to put clothes on. Then R20 was transferred to her wheelchair using a mechanical stand lift, V10 continued to touched multiple surfaces, adjusting R20 in the mechanical lift and positioning V10 in her wheelchair. After doing all these tasks was when she removed her gloves and washed her hands. On 11/20/24 at 8:30 AM, V11 (Registered Nurse-RN) said staff should wash their hands and change their…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-31 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility staff failed to ensure residents who required staff assistance with Activities of Daily Living (ADLs) received timely incontinence care for 2 of 4 residents (R2, R1) reviewed for ADLs in the sample of 9. The findings include: 1. R2's care plan dated 9/23/24 showed R2 required staff assistance with toileting and transferring. R2's resident assessment dated [DATE] showed R2 was frequently incontinent of urine and stool. On 10/31/24 at 8:44 AM, R2 was asleep in bed. A strong odor of urine was noted in her room. On 10/31/24 at 9:15 AM, R2 was awake, lying in bed. R2 stated, No one has come in yet this morning. I was last changed (provided incontinence care) late last night. The urine odor remained in R2's room. On 10/31/24 at 9:17 AM, V5 Certified Nursing Assistant (CNA) entered R2's room to provide cares. V5 (CNA) stated she had not toileted or provided incontinence care to R2 yet during her shift. As V5 (CNA) removed R2's incontinence brief, V5…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-31 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide 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 assist a resident with eating and failed to ensure a nutritional intervention was implemented for a resident with significant weight loss. This failure resulted in R4 sustaining significant weight loss. These failures apply to 1 of 4 residents (R4) reviewed for weight loss in the sample of 9. The findings include: R4's Physician Order Sheet (POS) showed R4 had diagnoses of Alzheimer's Disease (AD), dementia and diabetes. R4's careplan initiated on 11/22/23 showed (R4) is at nutritional risk related to score of 5 (malnourished), inadequate oral intake, significant weight loss, low BMI .confusion, delusions, AD, dementia . With intervention to include: provide nourishments: house shake 8 ounces (oz) BID (Twice a Day) with lunch and dinner. Provide supervision, encouragement/cueing, and necessary assistance at meal time and between meals with food and fluids. R4's weight report showed: 10/2/24-115.8 lbs, 6.2 % weight loss from 9/3/24 123.5 (1…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-24 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to protect a resident's right to be free from misappropriation of resident property. This applies to 1 of 4 residents (R1) reviewed for misappropriation in the sample of 8. The findings include: R1's face sheet list her diagnoses to include: urine retention, urinary tract infection, atrial fibrillation, heart failure, unilateral primary osteoarthritis of the left knee, morbid obesity, anxiety, osteoarthritis, muscle weakness and a history of malignant neoplasm of the breast. On July 24, 2024 at 8:45 AM, R1 was lying in bed watching television. She stated, she stole 30 of my pills. She stated, she told him (V5 Unit Manager) she (R1) was feeling dizzy but she never said that. The facility did call the police and they came and talked with her and her daughter. She stated, she didn't know her name but she was chubby and had curly hair. The facility's final incident report dated July 22, 2024 shows, Resident Name: (R1). Date of incident: 7/18/2024.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-27 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services 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 observation, interview, and record review the facility failed to ensure a resident's peritoneal dialysis treatments were initiated and monitored which applies to 1 of 1 resident (R1) reviewed for dialysis services in a sample of 1. The findings include: On 12/27/23 at 8:20 AM, V3 Assistant Director of Nursing stated R1 is the only peritoneal dialysis (PD) resident in the facility. R1's Facesheet printed on 12/27/23 showed R1 to be an eighty four year old female resident readmitted to the facility on [DATE] with diagnoses which include: chronic kidney disease (CKD) stage 5, encounter for fitting and adjustment peritoneal dialysis catheter, and dependence on renal dialysis. R1's hospital records dated 12/23/23 showed R1's PD orders which were in R1's hospital record packet. On 12/27/23 at 2:40 PM, V6 3rd party Dialysis Nurse showed this writer the treatment history on R1's PD cycler. The cycler screen showed R1's last 2 treatments were on 12/9/23 (evening before hospital admission) and 12/26/23 (3 days…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-06 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to implement physician ordered wound interventions for 1 of 24 residents (R93) reviewed for non-pressure wounds in the sample of 24. The findings include: On 12/05/23 at 2:45PM, R93 was in his room, in a wheelchair. R93's feet were resting on the floor. R93's AFO-ankle-foot orthosis Boots were sitting in a chair by the foot of the bed. On 12/05/23 R93's Physicians Order dated 09/30/23 shows, AFO Boots to be worn when out of bed. Every shift for Heel Wound. On 12/06/23 at 9:45AM, V6 Unit Manager said, R93 sees the podiatrist weekly for his wounds on his feet. R93 returns with a wound assessment and dressing instruction. There has been no new orders for the AFO boots. R93's current Care Plan, updated 09/27/2023 shows, R93 has potential/actual impairment to skin integrity-admitted with non-pressure chronic ulcer of right foot, Interventions: R93's Care Plan did not address the Physician Ordered AFO Boots for Heel Wound. The facility's Skin Maintenance policy dated 01/20/2022 shows, the physician will order pertinent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-06 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a soiled dressing was changed, failed to reposition a resident with pressure injuries, and failed to have pressure relieving interventions in place for 2 of 5 residents (R40, R81) reviewed for pressure injuries in the sample of 24. The findings include: 1. R40's Care Plan shows R40 was admitted to the facility on [DATE], with diagnoses including anxiety disorder, anemia, Alzheimer's disease, epilepsy, adult failure to thrive, and dementia. R40's Care Plan initiated on February 21, 2023, shows R40 is at risk for skin impairment related to decreased mobility skills, incontinence, and fragile skin. November 30, 2023-superficial abrasion to mid-lower back. Unstageable left lateral fifth toe. December 5, 2023-unstageable pressure injury lower mid spine. Assist to turn and reposition. R40's Pressure Injury Risk score dated November 30, 2023, shows R40 is a high risk for developing pressure injuries. On December 4, 2023, R40 was observed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure fall interventions were in place for a resident with a history of falls. This applies to 1 of 24 residents (R51) reviewed for safety in the sample of 24. The findings include: R51's face sheet shows he is a [AGE] year old male with diagnoses including unspecified psychosis, unspecified dementia, parkinsonism, history of falls, repeated falls, ataxic gait, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R51's Fall Risk assessment dated [DATE] shows he is a HIGH risk for falls. R51's Physician Order Sheets dated through December 2023 shows orders for the bed to keep in lowest position while in bed, apply landing pad (floor mat) on the right side of the bed. On 12/5/23 at 9:06 AM, R51 was observed lying in bed. The floor mat was folded in the corner of his room. R51 said he's had a fall prior but could not recall the details of the event. On 12/5/23 at 1:22 PM, R51 was observed lying in a low…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-06 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to assess a resident's pain every shift and provide pain medication prior to therapy. This applies to 1 of 24 residents(R23) reviewed for pain in the sample of 24. The findings include: On 12/4/2023 at 10:13AM, R23 said she is at the facility for therapy following a fall at home resulting in pelvic fracture. R23 said surgery was not recommended for her fracture by her doctors, but physical therapy and rest were. R23 said she does have pain from the pelvic fracture and has pain medications ordered for it. R23 said she doesn't always get pain medications before therapy because of timing and nurse availability. R23 said she would like pain medication before therapy to help her get through therapy. On 12/5/2023 at 9:35AM, V11 RN-Agency said she had not seen [R23] yet this morning. On 12/5/2023 at 9:56AM, V8 Physical Therapy Assistant (PTA) said she sees [R23] 5 times per week for therapy. V8 said [R23] has therapy scheduled for 45 minutes, but it is usually broken up into two shorter sessions due to [R23] having…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-06 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure a residents insulin vial was disposed of after 28 days of opening and failed to ensure a medication vial for anti-anxiety was dated and labeled upon opening. This applies to 2 of 6 residents (R80 and R37) reviewed for medication storage in the sample of 24. The findings include: 1. On 12/5/23 at 8:39 AM, the medication cart on the memory unit was inspected with V5 (Registered Nurse). R80's insulin (Humalog) vial was labeled with an open date of 10/23/23 and an expire date of 11/25/23. R5 said insulin should be disposed after 28 days of use. R80's Physician Order Sheets dated through December 2023 shows orders for Humalog inject 7 units at breakfast and dinner and inject 5 units at lunch. The facility's Insulin Administration Policy dated 1/22, states, Check expiration date if drawing from an opened multi-dose vial. If opening a new vial, record expiration date and time on the vial (follow manufacture recommendations for expiration after opening). 2. On 12/6/23 at 8:57 AM, the medication room on 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$25,454 in federal fines across 2 penalties.
- $10,413 — penalty dated 2024-10-31
- $15,041 — penalty dated 2024-07-24
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| ENCORE VILLAGE HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 12/28/2023 |
| BARAX, HARRY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | NO PERCENTAGE PROVIDED | since 12/28/2023 |
| NORMAN, DANIEL | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | NO PERCENTAGE PROVIDED | since 12/28/2023 |
| SATT, AVRAHAM | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | NO PERCENTAGE PROVIDED | since 12/28/2023 |
| PEPLOW, MICHAEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/28/2020 |
| RIEL, TAYLOR | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/23/2024 |
CMS files one row per role, so the 11 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner 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 $5.6M paid to related parties — landlords or management companies under common ownership — equal to about 11% 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.
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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145341. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-29, 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.