Tower Hill Healthcare Center
759 Kane Street, South Elgin, IL 60177 · For profit - Partnership · 206 certified beds · (847) 697-3310 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- CMS has flagged it for abuse
- it has abuse, neglect, or exploitation citations (F0600, F0607, F0609) — most recent May 2026
- inspectors cited 3 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (55) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $57,365 in federal fines (most recent 2024-05-16)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 1 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 1 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 | 15.9% | 13.4% | 15.4% | typical |
| Long-stay residents who lose too much weight | 8.9% | 6.3% | 5.4% | worse |
| 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 | 79.0% | 54.2% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.2% | 0.1% | 0.1% | worse |
| Long-stay residents with falls causing major injury | 2.2% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 17.3% | 14.3% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 19.4% | 18.3% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 78.4% | 91.8% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 3.1% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 17.1% | 20.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 30.9% | 21.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 14.0% | 63.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 24.2% | 26.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 20.6% | 13.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.37 | 2.02 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 4.11 | 2.22 | 1.80 | worse |
‡ 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.
46.4% 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 40 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 40.8% 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 0.23 therapist hours per resident per day in 2026Q1 — more than 30% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% 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 | 46.4%CMS range 32.8–65.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.3%CMS range 6.9–15.4 | 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 | 40.8% | 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 | 38.8% | 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 | 36.7% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 90.9% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.6% | 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 | 9.1% | 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 | 10.1%CMS range 5.5–15.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.42 | 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 206 beds and averages 173.2 residents a day — about 84% occupied, or roughly 33 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 2.74 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.36 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.83 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 2.46 hrs/resident/day on weekends vs 2.86 on weekdays — 14% thinner on weekends. RN hours go from 0.41 to 0.23 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 38% 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.
55 citations, most serious first. The 16 most serious are shown; the remaining 39 are one tap away and print in full.
- Immediate jeopardy · Jcited before2024-03-15 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
B. Based on observation, interview, and record review, the facility failed to ensure a resident was free from sexual abuse (R61), and failed to ensure residents were free from verbal abuse (R80 and R52), for 3 of 32 resident reviewed for abuse in the sample of 32. 1. The Facility Reported Incident (FRI) as Final Report, dated 3/5/24 with date of incident as 3/1/24, shows (R61) was observed to have his hand on (R132's) breast. Both residents were on 2nd floor. (R132) was up and about, while (R61) was sitting in his wheelchair able to wheel himself around. Both were in the nurse station on 2nd floor, several staff were behind the nurses station documenting. Upon looking, it was observed that (R61) had his hand on (R132's) left breast. Upon observation, staff immediately intervened and separated the two residents. R132 is a 73 y/o female with diagnoses of Alzheimer's disease, hyperlipidemia, major depression recurrent, muscle weakness unsteadiness on feet . alert and oriented x1, with impaired memory judgement and decision making abilities. R132 is unable to make her wants and needs…
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.
- Immediate jeopardy · J2024-03-15 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to follow their abuse policy and procedure by not protecting R102 from abuse by not removing a staff members who's observed actions were suspected to be abusive, and not performing a full body assessment of a resident who was suspected of being abused for 1 of 36 residents (R102) reviewed for abuse in the sample of 36. The Immediate Jeopardy began on 03/09/2024 at 12:30AM, when V38, CNA-Certified Nursing Assistant, failed to report her suspicion of abuse when she observed V37, CNA, becoming aggressive, grabbing R102's hands and pinning them down to R102's chest, resulting in R102 being abused by V37, CNA, at 5:30AM. V1, Administrator, was notified of the Immediate Jeopardy on 03/14/2024 at 4:00 PM. The surveyor confirmed by interview and record review the Immediate Jeopardy was removed on 03/14/2024, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: On 03/13/24 at 1:46 PM, R102 was lying in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · J2024-03-15 · 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 observation, interview, and record review the facility failed to immediately report a suspicion of physical abuse for 1 of 36 residents (R102), and failed to ensure and allegation of verbal abuse was immediately reported for 1 of 32 residents (R80) reviewed for abuse in the sample of 36. The Immediate Jeopardy began on 03/09/2024 at 12:30AM, when V38, CNA-Certified Nursing Assistant, failed to report her suspicion of abuse when she observed V37, CNA, becoming aggressive, grabbing R102's hands and pinning them down to R102's chest, resulting in R102 being abused by V37, CNA, at 5:30AM. V1, Administrator, was notified of the Immediate Jeopardy on 03/14/2024 at 4:00 PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 03/14/2024, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: 1.On 03/13/24 at 1:46 PM, R102 was lying in bed on his back, with the head of the bed elevated at a thirty-degree angle. R102 had 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.
- Actual harm · Gcited before2026-04-22 · 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 resident, who was at risk for skin breakdown, was kept clean and dry, and did not develop a pressure ulcer.This failure resulted in the development of a stage 2 pressure ulcer to the resident's buttock. This applies to 1 or 3 residents (R1) reviewed for improper nursing care in the sample of 8. Findings include: R1's electronic medical record showed R1 to be [AGE] years old and admitted to the facility with diagnoses that include muscle weakness, unsteadiness on feet, other lack of coordination, acute kidney failure, dysphagia, schizophrenia, schizoaffective disorder, generalized anxiety disorder, and syncope and collapse. R1's Minimum Data Set (MDS) dated [DATE], showed R1 to have severe cognitive impairment. R1's MDS also showed R1 required substantial/maximal assistance with toileting hygiene.R1's most recent readmission assessment dated [DATE], showed that R1 was at risk for developing pressure sores and showed he did 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.
- Actual harm · Gcited before2024-05-16 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to protect residents from abuse per their facility abuse prevention program. This applies to 3 of 4 residents (R1, R3 and R4) reviewed for abuse in the sample of 6. The failure resulted in R1 experiencing ongoing head, neck and shoulder pain as a result of R2 hitting R1. The findings include: 1. Face sheet, dated 5/15/24, shows R2's diagnoses included dementia, psychosis, muscle weakness, malignant neoplasm of bladder, cognitive communication deficit, reduced mobility, and history of falling. The MDS (Minimum Data Set), dated 2/3/24, shows R2's cognition was severely compromised. Face sheet, dated 5/15/24, shows R1's diagnoses included dementia, cognitive communication deficit, mild cognitive impairment, abnormal gait/mobility, and unsteadiness on her feet. The MDS, dated [DATE], shows R1's cognition was severely impaired. On 5/16/24 at 11:46 AM, R1 stated a week ago Sunday R2 punched her in her chin. R1 stated her chin, neck, and shoulders continued 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.
- Actual harm · Gcited before2024-03-15 · 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 assess and identify a sacral pressure injury for R13, failed to assess and identify a pressure injury to left heel and left elbow for R73,and failed to ensure a wound did not get worse to 3 of 7 residents (R13, R73 and R31) reviewed for pressure injury in the sample of 32. This failure resulted in R13 having a stage 3 acquired pressure injury, and R73 having a deep tissue injury (DTI). The findings include: 1.R13 face sheet shows R13 is [AGE] year old who was originally admitted to the facility on [DATE], with diagnoses that include dementia, diabetes, stroke and chronic kidney disease dependent on dialysis,. R13's Braden scale (predicting pressure score risk), dated 1/11/24 , shows R13 is at high risk for developing pressure. R13's skin admission assessment, dated 1/11/24 shows R13 had no pressure injury. R13's Wound Assessment details report, dated 3/8/24 show, wound sacrum, type pressure (injury), facility acquired, date identified…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-11 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure residents that were cognitively impaired were free from physical abuse. This applies to 2 of 10 residents (R2 and R4) reviewed for physical abuse. The findings include: 1.Review of the Electronic Medical Record (EMR) showed that R2 was admitted to the facility on [DATE]. R2 was a [AGE] year-old female with diagnoses that included dementia, schizophrenia, delusional disorder, auditory hallucinations, hemiplegia, neuropathy, legal blindness, and hearing loss. R2 was assessed as alert and oriented times one to two, with impaired memory, judgment, and decision-making abilities, and severe cognitive impairment. Review of the EMR further showed multiple psychiatric and nursing notes documenting intermittent delusions, paranoia, medication refusal, and periods of tension. However, there was no documented history of physical aggression toward peers or staff. Review of the EMR showed that R1 was admitted to the facility on [DATE]. R1 was a [AGE]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-24 · 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 serve a resident with multiple sclerosis and dementia hot coffee in a safe manner for 1 of 6 residents (R1) reviewed for safety in the sample of 6.The findings include:On 4/24/26 at 10:02 AM, R1 was sitting in his wheelchair in the dining room watching a movie. R1 said he liked the coffee at the facility. R1 said a few days ago he spilled coffee in his lap, but it was all healed up now. R1 said the coffee is not too hot; he likes it just the way it is. On 4/24/26 at 8:45 AM, V6 Wound Licensed Practical Nurse said R1 was accidently burned when he spilled coffee in his lap. V6 said R1 sustained a second degree burn to his left inner thigh. V6 said R1 was in dining room when it happened, and staff immediately brought him to his room and removed his pants and applied ice to the area. V6 said she was notified and responded to R1's room. V6 said R1's left inner thigh was just red at that time and ice and silver burn cream was applied. V6 said…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-22 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident, who was at risk for skin breakdown, was kept clean and dry. This applies to 1 of 3 residents (R1) reviewed for improper nursing in the sample of 8.Findings include: R1's electronic medical record showed R1 to be [AGE] years old and admitted to the facility with diagnoses that include muscle weakness, unsteadiness on feet, other lack of coordination, acute kidney failure, dysphagia, schizophrenia, schizoaffective disorder, generalized anxiety disorder, and syncope and collapse. R1's Minimum Data Set (MDS) dated [DATE], showed R1 to have severe cognitive impairment. R1's MDS also showed R1 required substantial/maximal assistance with toileting hygiene.R1's most recent readmission assessment dated [DATE], showed that R1 was at risk for developing pressure sores, and it showed R1 did not have any wounds on his buttocks. R1 had the following care plans: 1) R1 is incontinent of bowel and bladder. 2) R1 has a potential for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-27 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
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 grievance was reported and resolved for a resident's missing items. This applies to 1 of 10 residents (R5) reviewed for grievances in the sample of 10. The findings include: R5's nursing note dated 3/20/25 by V12 (RN) documents (R5) stated he has clothes and money missing and no one is doing anything. On 3/27/26 at 1:45 PM, V12 (RN) said she documented the note on 3/30/25 regarding R5's missing clothes and money. If a resident reports missing items she reports the items to V9. V12 said she could not recall if she reported the missing items to V9. On 3/27/26 at 1:52 PM, V9 (Social Services) said when a resident reports missing money or clothes. She takes 48 hours trying to find the item. After 48 hours if she cannot locate the item, she will file a grievance form and replace the item. V9 said she was not aware of R5's reported missing items on 3/30/25. She has educated staff to report to her if a resident reports missing items. If she doesn't know what's missing, she can't follow up. The facility's Grievance…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-27 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure residents were free from physical abuse for 2 of 8 residents (R1, R3) reviewed for abuse in the sample of 10. The findings include:The facility's Initial Incident Report shows It was reported that R1 grabbed papers from R2. In R2's attempt to get them back, R2 struck R1 in the face, right side of cheek. Both residents were immediately separated and assessed for injuries. On 3/27/26 at 9:20 AM, R1 was sitting in a wheelchair in her room. R1 was dressed and well groomed. When asked about any concerns with other residents, R1 said she got hit in the face by a male person. R1 appeared anxious, with shaking hands, and said it was scary. R1 became quiet and didn't respond to questions about the details of the incident but did state that she has not seen the man since. R1 said she has not been bothered by anyone before or since. On 3/27/26 at 10:26 AM, V7 Certified Nursing Assistant (CNA) said she saw R2 standing next to R1 who was in her wheelchair in front of R2's room. V7 said R2 grabbed something from R1's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-07 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure residents were free from physical abuse. This applies to 3 of 4 residents (R2, R4, R5) reviewed for abuse in the sample of 13. The findings include: 1. The facility's undated Final Abuse Investigation shows (R4) is male resident with diagnoses including unspecified dementia, restlessness and agitation, generalized muscle weakness, vascular dementia, and osteoarthritis. (R4) is alert and oriented x1 with severe cognitive impairments with short- and long-term memory, judgement and decision-making abilities. He relies on staff for cueing and redirection, often paces the facility and has exit seeking behaviors. He tends to wander around the unit and requires frequent redirection.(R5) is a female resident with diagnoses including other psychotic disorder, major depressive disorder, generalized anxiety, glaucoma, and cognitive communication deficit. (R5) is alert and oriented x 1-2 with severe cognitive impairments and also has impaired short- and long-term memory, judgement and decision-making abilities. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-07 · 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 interview and record review the facility failed to ensure a resident was transported via wheelchair in a manner to prevent a resident fall for 1 (R5) of 3 residents reviewed for safety and supervision in the sample of 13.The findings include:R5's resident assessment dated [DATE] showed R5 was severely cognitively impaired.R5's care plan dated 6/18/25 showed R5 was at risk for falls related to her poor safety awareness and impulsiveness due to her impaired cognition. R5 also had diagnoses of glaucoma, previous falls with fractures, anxiety, unspecified psychotic disorder, and a cognitive communication deficit which contributed to R5's increased risk of falling.R5's progress note dated 9/15/25 showed R5 was being pushed in her wheelchair by a restorative certified nursing assistant (CNA) when R5 suddenly planted her feet down on the ground as her wheelchair was moving, causing R5 to fall forward out of her wheelchair, onto the floor. R5 landed on her knees and then rolled over onto her back on the floor.…
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 before2025-08-12 · 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 interview and record review, the facility failed to ensure antidepressant medication was obtained from the pharmacy in a timely manner to prevent a resident from missing medication doses as ordered by the physician.This applies to 1 of 3 residents (R1) reviewed for quality of care in the area of missing antidepressant medications in the sample of 5.The findings include:The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE], and was discharged to home on July 1, 2025. R1 had multiple diagnoses including, traumatic brain injury with loss of consciousness, anoxic brain damage, other specified depressive episodes, Parkinsonism, psychoactive substance dependence, generalized anxiety disorder, depressive episodes, atrial fibrillation, and anemia. R1's MDS (Minimum Data Set) dated June 30, 2025 shows R1 had moderate cognitive impairment, required setup assistance with toilet hygiene and showering, and supervision with all other ADLs (Activities of Daily Living). R1 was always…
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 before2025-07-01 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent abuse between two residents. This applies to 2 of 4 residents (R1, R2) reviewed for abuse in a sample of 5. The findings include: R1 and R2's initial report dated 6/9/25 that was reported to IDPH (Illinois Department of Public Health) shows the following: (R1) allegedly struck (R2) this morning near a common area. Both residents were immediately separated and assessed for any injuries. Police were called and report filed. Medical doctors and Power of attorneys were made aware of the alleged incident. Full investigation to follow. R1and R2's final report shows the following: On 6/9/25, (V4-CNA/Certified Nursing Assistant) was in another resident's room providing care to that resident. Upon exiting the room, she overheard (R1) and (R2) engaged in what appeared to be a physical altercation at the opposite end of the building (West Hallway). (V4) also witnessed (R2) who was standing out of his wheelchair and back to (V4) swinging his arms at (R2).…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-28 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to complete neurological assessments following a fall. This applies to 1 of 3 (R1) resident reviewed for falls. The findings include: On 4/28/2025 at 9:01AM, R1 was observed laying in his bed with the head of bed elevated watching his computer with headphones on. R1 did not appear to have any bruising or swelling on his head. On 4/28/2025 at 9:01AM, R1 said he fell out of bed a day or two after he arrived at the facility. R1 said he hit his head when he fell. R1 said he went out to the hospital and returned the same day. On 4/28/2025 at 12:13PM V7 Restorative Nurse said neuro checks are done for 72 hours post fall. V7 said neuro checks should have resumed when [R1] returned from the hospital. On 4/28/2025 at 11:36AM, V2 Director of Nursing (DON) said neuro checks are done for an unwitnessed fall or when a resident hits their head for 72 hours after the fall. V2 said neuro checks are important because they help identify changes in condition. V2 said neuro checks should be continued when a resident returns from the hospital.…
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.
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- Potential for harm · D2025-03-18 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to maintain a residents dignity by not answering a call light in a timely manner for 1 of 3 residents (R1) reviewed for dignity and resident rights in the sample of 5. The findings include: On 3/18/25 at 10:00 AM, V15 (R1's great - granddaughter) stated her and a relative were visiting R1 on 3/9/25. When she arrived around 11:30 AM, R1 needed to use the bathroom and her call light was on. V15 stated they went to the nurse's station to get a staff member because no one came to help. V15 stated she went and asked again because no one had come to help R1 and was told they would be down in a few minutes. V15 stated no one came to R1's room to toilet her. V15 stated she went and asked for assistance again and was told they were in the middle of lunch, needed to pass trays, and had other people to help. V15 stated by the time she got back to R1's room, R1 had wet herself. V15 stated R1 had to sit like that for awhile (10-20 minutes) and that is not right. V15 stated no one should have to sit in it. V15 stated it took 40 minutes - 60…
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 before2025-02-27 · 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 residents were prevented from having access to a room where medical equipment in need of repair was being stored. This applies to 1 of 3 residents (R4) reviewed for accidents in the sample of 5. The findings include: The EMR (Electronic Medical Record) shows R4 was admitted to the facility on [DATE]. R4 has multiple diagnoses including, cerebral infarction, lack of coordination, reduced mobility, muscle weakness, unsteadiness on feet, abnormal gait, cognitive communication deficit, repeated falls, gastrostomy, right shoulder pain, fatty liver, dysphagia, hemiplegia and hemiparesis of the right dominant side, dizziness and giddiness, and dementia. R4's MDS (Minimum Data Set) dated November 27, 2024 shows R4 is cognitively intact, requires supervision with eating, oral hygiene, dressing, and personal hygiene, partial/moderate assistance with showering, and substantial/maximal assistance with toilet hygiene, bed mobility, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-02-06 · tag F0881 — failed to use antibiotics responsibly — widespreadImplement a program that monitors antibiotic use.
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 protocols in place to utilize an assessment tool or management algorithm for residents who may receive antibiotics. This applies to all 166 residents residing in the facility. The findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid dated February 3, 2025, showed the facility's census was 166 residents. On February 5, 2025, at 9:31 AM, V4 (Infection Preventionist) said when a resident has an infection and an antibiotic is used, V4 does not utilize an assessment tool or criteria when assessing if a resident is appropriately receiving an antibiotic. V4 said she reviews antibiotic orders with the providers to ensure there is an indication for use. On February 5, 2025, at 10:56 AM, V4 provided Infection Surveillance Monthly Reports for December 2024, January 2025, and February 2025. V4 said she did not have an assessment tool for any of the antibiotics prescribed during those months. V4 said she does not complete an assessment tool for any antibiotics prescribed to residents in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-02-06 · tag F0805 — failed to prepare food in a form residents can eat — patternEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
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 prepare mechanical soft consistency diets for residents that had a diet order for the same. This applies to 4 of 4 residents (R27, R108, R111, R136) reviewed for dining in the sample of 33. The findings include: Facility Fall/Winter Menu week at a glance for mechanical soft (week 2, Tuesday, February 4) showed ground BBQ (barbeque) pork shoulder as the main entrée for lunch meal. On February 4, 2025 at 9:41 AM, the preparation for mechanical soft consistency BBQ pork was observed in the facility kitchen. V9 (Cook) took several slices of cooked pre sliced pork and placed it on a cutting board and when asked if he is going to grind it, V9 stated that he is going to shred it into small pieces and add some broth and barbeque sauce which would make it soft. V9 then diced the pre sliced cooked pork into small pieces (about an inch) on a cutting board with a knife. V9 was notified that after preparation, the final consistency will be checked to see if appropriate for mechanical soft consistency. Prior to preparation…
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 before2025-02-06 · 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 provide grooming assistance for residents that needed extensive assistance from staff. This applies to 2 of 5 residents (R3, R58) reviewed for ADLs (activities of daily living) in the sample of 33. The findings include: R3's face sheet included diagnoses of cerebral infarction, functional quadriplegia, paraplegia, dysarthria following cerebral infarction, hemiplegia, unspecified affecting left nondominant side. R3's quarterly MDS (minimum data set) dated November 8, 2024 showed that R3 was moderately impaired in cognition and was dependent on staff for personal hygiene. On February 3, 2025 at 11:34 AM, R3 was seated in her bed and both her hands appeared contracted with the left hand more pronounced. R3's right hand fingernails appeared very long and thick with few curling in and rubbing against her palms. R3 was holding a washcloth on her left hand and the fingernails on the same hand was not visible. When asked, R3 stated that she would…
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 · D2025-02-06 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to change residents' central venous catheter dressing in a timely manner to prevent the spread of infection. This applies to 2 of 2 residents (R310 and R309) reviewed for intravenous catheter dressing changes in the sample of 33. The findings include: 1. R310's face sheet showed her to be an [AGE] year old female admitted to the facility on [DATE] with diagnoses that include Infection following a procedure, superficial incisional surgical site, subsequent Encounter, Presence of Left Artificial Hip Joint, and Unilateral Primary Osteoarthritis, Left hip. On February 4, 2025 at 12:35 PM during medication administration observation, V23 (Licensed Practical Nurse), observed R310's central line dressing was dated January 8, 2025, and was dingy, loosened, and detached from her skin on the top right side of her right arm. R310 stated that the dressing was placed on her arm on January 8, 2025 and no one has changed the dressing since then. R310 stated…
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 · D2025-02-06 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to manage a resident's complaint of severe pain. This applies to 1 of 3 residents (R41) reviewed for pain in the sample of 33. The findings include: R41 face sheet showed her to be an [AGE] year old female admitted to the facility on [DATE] with diagnoses including Fracture of shaft of right Tibia, subsequent Encounter for closed fracture with routine healing, Low back pain, , Pain in Left hip, chronic pain, pain in right hip, and Unspecified Osteoarthritis. As of February 5, 2025 at 10:25 AM, R41 did not have a care plan for pain. On February 3, 2025 at 10:33 AM, R41 stated she had pain in her right leg pain at 10 on a scale of 0 to 10 (0 being no pain and 10 being severe pain). R41 stated the facility does not give her pain medication timely. R41 stated she takes Hydrocodone and it helps if it is given on time. On February 3, 2025 at 10:40 AM, V23 (Nurse) stated that he already gave R41 pain medication this morning but he would check on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-06 · 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 maintain central venous catheter dialysis access site in accordance with infection control standards and their policy. This applies to 1 of 4 residents (R119) reviewed for dialysis in the sample of 33. The findings include: R119 was admitted to the facility on [DATE], with multiple diagnoses including end stage renal disease with dependence on renal dialysis, diabetes, essential hypertension, chronic pain syndrome, and secondary and unspecified malignant neoplasm of lymph nodes, multiple regions. R119's MDS (Minimum Data Set) dated January 16, 2025, showed R119 was moderately cognitively impaired and required assistance with ADLs (Activities of Daily Living) including set up assistance with eating, personal, oral, toilet hygiene and toilet transfer. R119's care plan for dialysis created January 9, 2024, showed to monitor access site for signs of infection but did not address care of insertion site for the central venous catheter device.…
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 · D2025-02-06 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow their policy to have the physician respond in a timely manner to the pharmacist's monthly Medication Regimen Review recommendations. The facility also failed to follow their policy to conduct monthly Medication Regimen Reviews for a resident. This applies to 3 of 5 residents (R39, R122, and R128) reviewed for unnecessary medications in the sample of 33. The findings include: 1. The EMR (Electronic Medical Record) showed R122 was admitted to the facility on [DATE], with multiple diagnoses including atrial fibrillation, depression, muscle weakness, and history of falling. R122's MDS (Minimum Data Set) dated November 29, 2024, showed R122 had moderate cognitive impairment. The MDS continued to show R122 had not received any as needed pain medication and did not have any pain present. R122's Order Summary Report dated February 5, 2025, showed an order dated April 2, 2024, for hydrocodone-acetaminophen (narcotic pain medication) oral tablet 5/325 mg…
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 · D2025-02-06 · 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 interview and record review, the facility failed to follow their policy to attempt gradual dose reductions for residents receiving psychotropic medications. This applies to 3 of 5 residents (R73, R91, and R128) reviewed for unnecessary medications in the sample of 33. The findings include: 1. R73's EMR (Electronic Medical Record) showed R73 was admitted to the facility on [DATE], with multiple diagnoses including unspecified dementia with other behavioral disturbance, seizures, generalized anxiety disorder, major depressive disorder, and unspecified psychosis. R73's MDS (Minimum Data Set) dated November 7, 2024, showed R73 had severe cognitive impairment. The MDS continued to show R73 did not exhibit any behaviors of psychosis, physical behavior symptoms directed toward others, verbal behavioral symptoms directed toward others, or other behavioral symptoms not directed towards others. R73's Order Summary Report dated February 5, 2025, showed an order dated May 24, 2023, for clonazepam (antianxiety…
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 before2025-02-06 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the 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 use scoop size as shown for pureed diets as shown on menu. This applies to 3 of 3 residents (R14, R65, R90) reviewed for dining in the sample of 33. The findings include: On February 3,2025 at 11:40 AM, the tray line was observed in the facility kitchen with V9 (Cook) serving the regular and mechanical soft consistencies and V8 (Dietary Manager) serving the pureed meals. V8 was using a #8 scoop to serve pureed chicken and pureed pasta and R14, R65 and R90 received the same. Menu spread sheet for fall/winter menu (week 2) that was posted on the wall at side of the tray line steam table, showed that the residents on pureed diets to receive pureed Chicken [NAME] #6 scoop =2 oz/ounce protein, pureed Penne #6 scoop. When asked why the #8 scoop was used instead of #6 scoop, V8 turned to V9 and stated that he was supposed to check the menu before placing the scoops. On February 5, 2025 at 11:37 AM, V12 (Dietitian) stated that the dietary staff should use the scoops that is called for on the menu spreadsheet. V12…
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 · D2025-02-06 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure 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 provide a resident with a pureed diet per physician orders. This applies to 1 of 3 residents (R14) reviewed for pureed diets in the sample of 33. The findings include: On February 4, 2025, at 11:42 AM, R14 was sitting in the dining room with a meal tray on the table in front of her. The meal tray given to R14 was a regular texture meal with barbecue pulled pork, tater tots, and corn bread. The meal tray was not pureed texture. V18 (CNA/Certified Nursing Assistant) assisted R14 by cutting up the food on the tray. R14 started eating the lunch tray. V3 (ADON/Assistant Director of Nursing) said R14 had an order for a pureed diet, but the tray in front of R14 was a regular texture diet. V3 removed the tray and said the tray served to R14 was a different resident's tray and R14 should have been served the correct diet. The EMR (Electronic Medical Record) showed R14 was admitted to the facility on [DATE], with multiple diagnoses including…
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 before2025-02-06 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their policies for norovirus, contact precautions, and enhanced barrier precautions. This applies to 3 of 33 residents (R7, R14, and R124) reviewed for infection control in the sample of 33. The findings include: 1. The EMR (Electronic Medical Record) showed R14 was admitted to the facility on [DATE], with multiple diagnoses including stroke, dementia, dysphagia, and facial weakness following a stroke. R14's Laboratory Result Report showed R14 had a stool specimen collected on January 31, 2025, and on February 2, 2025, it was reported norovirus was detected in the specimen. On February 3, 2025, at 11:35 AM, V17 (Licensed Practical Nurse) said R14 was not in her room and was in the therapy department. On February 3, 2025, at 12:21 PM, R14 was in the dining room eating lunch at a table with two other residents. On February 4, 2025, at 11:42 AM, R14 was sitting in the dining room, eating lunch at a table with three other residents. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-26 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent abuse between two residents. This applies to 2 of 4 residents (R1, R2) reviewed for abuse in a sample of 4. The findings include: On 12/24/24 at 8:55 AM, through the assistance of V5 (LPN-Licensed Practical Nurse) who translated in Spanish, R2 stated the following: (R1) grabs other people's food from their trays. (R1) grabbed my food in the second floor dining room. Then, I told him not to take my food. (R1) then hit me in the face. I didn't hit back. Staff came and stopped the fight. I landed on the floor. I had no injuries. I don't remember scratching (R1), but I saw a little bit of blood on his neck area. (R1) was not sitting next to me. He just came and grabbed my food. (R1) never did this before to me. I behave because I want to go home. The nurse checked me out. I don't remember if I went to the hospital, but I think got x-rays. It's just an accident that happened between us. On 12/24/24 at 8:47 AM, V4 (Social Service Director) stated, I…
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 before2024-12-12 · 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
Based on interview and record review, the facility failed to safely transfer a resident through a mechanical lift from her wheelchair to her bed. This resulted in R1 having a fall. This applies to 1 of 3 residents (R1) reviewed for transfers in a sample of 6. The findings include: On 12/10/24 at 11:15 AM, V2 (DON-Director of Nursing) stated, (R1) is no longer here. She was discharged AMA (Against Medical Advice). She was a 2 person assist with a (mechanical lift). She came to us on 11/4/24. On 11/11/24, (R1) was getting transferred from her wheelchair to the bed after dialysis in her room with the mechanical lift. (V4--Former CNA/Certified Nursing Assistant) and (V3) were the CNA's that were transferring her. (V3) no longer works here. (R1) was moving around in the sling while they were transferring her. She wouldn't stop. She slid off the sling and fell to the floor. She had no injuries. (R1) was sent to the hospital. X-rays were done and everything was normal. Falls are not supposed to happen when you transfer a resident using the (mechanical lift). On 12/10/24 at 11:55 AM, V3…
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 before2024-12-12 · 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 failed to follow current standards of infection control during a pressure dressing change. This applies to 2 of 2 residents (R6, R7) reviewed for infection control in a sample of 7. The findings include: 1. On 12/10/24 at 2:01 PM, surveyor went with V9 (Wound Nurse/LPN-Licensed Practical Nurse) to R6's room. On R6's door, there was sign that said Contact Isolation/Precautions. V9 stated R6 had C-Diff (Clostridioides Difficile). On 12/10/24 at 2:08 PM, V9 washed her hands with soap and water. She put on gloves. V9 removed R6's heel boots, socks and pressure ulcer dressing. She then removed her gloves and used hand sanitizer to sanitize her hands. She put on gloves and then cleansed the wound with normal saline and gauze. V9 removed her gloves and washed her hands with soap and water. V9 put on gloves and applied medi-honey and a foam dressing with border onto R6's wound. Then she put R6's socks and heel boots on. V9 removed her gloves and washed her hands with soap and water while wearing her dirty gown. With her washed…
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 before2024-11-01 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to prevent physical abuse of a resident residing at the facility. This applies to 1 of 6 residents (R3) reviewed for abuse. The findings include: On 10/29/24 at 10:46 AM, R3 said he was sitting in the dining room when R2 approached his table wanting to sit at his table. R3 said he told R2 that the space belonged to another resident. R3 said R2 got upset and started hitting him. R3 said he raised his arms up to block R2 from hitting him on his face, but R2 managed to hit him on the left side of the face and his face was red and it hurt. R2 said R3 punched him with two fists and was hitting his arms. R3 said he did not hit or touch R2. R3 said staff intervened at took R2 away. On 10/29/24, 10/30/24 and 10/31/24, R2 was observed several times resting in his room. R2 was not interviewable. R2's Face Sheet shows the following diagnoses of encephalopathy, dementia, and Alzheimer's disease. R2's Minimum Data Set (MDS) of 10/17/24 shows that R2's cognition skills for decision making was moderately impaired. R3's Face Sheet shows 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 before2024-10-10 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent the physical abuse of a resident residing at the facility per facility policy. This applies to 1 of 3 residents (R1) reviewed for abuse in a sample of 3. The findings include: Face sheet, dated 10/9/24, shows R1's diagnoses included dementia, cognitive communication deficit, restlessness and agitation, and encephalopathy. MDS (Minimum Data Set), dated 7/3/24, shows R1's cognition was severely compromised. Face sheet, dated 10/9/24, shows R2's diagnoses included person injured in unspecified motor-vehicle accident and acquired absence of left leg above knee. MDS, dated [DATE], shows R2 was cogitatively intact. Final abuse investigation report, submitted to IDPH (Illinois Department of Public Health) on 10/4/24, shows, On 9/30/24, [R1] and [R2] were both residing on the 2nd floor in different rooms. Staff were in the dining area serving breakfast when they hear a disturbance/commotion. Staff observed [R1] and [R2] engaging in a physical…
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 · F2024-07-18 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to serve lunch palatable and at a safe and appetizing temperature. This applies to all 154 residents consuming food from the kitchen. The findings include: 1. R1 is a [AGE] year-old male admitted on [DATE] with mild cognitive impairment as per the Minimum Data Set, dated [DATE]. On 7/16/24 at 11:00 AM, R1 stated, The food is not edible. Even the family dog won't even eat it. 2. R3 is a [AGE] year-old female admitted on [DATE] with mild cognitive impairment as per the MDS dated [DATE]. On 7/16/24 at 10:15 AM, R3 stated, Majority of part, food is OK. I am not saying food is perfect. There are some issues like cold food and not appetizing. 3. R4 is a [AGE] year-old female admitted on [DATE] with moderate cognitive impairment as per the MDS dated [DATE]. On 7/1/24 at 10:45, R4 stated, Food is the same, not that warm, and is kind of cold. On 7/16/24 at 11:25 AM, the kitchen tray service was observed. The savory pork roast was observed 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.
- Potential for harm · D2024-07-18 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
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 provide residents with a clean, comfortable, home-like interior. This applies to 2 of 6 residents (R1 and R2) reviewed for the sanitary, comfortable, home-like environment. The findings include: R1 is a [AGE] year-old male admitted on [DATE] with mild cognitive impairment as per the Minimum Data Set, dated [DATE]. On 7/16/24 at 11:00 AM, R1 was observed in his clean room with a bed sheet with holes, window curtains with mold buildup on the bottom of the right curtain panel, and a bathroom plumbing leak, causing stains on the floor underneath the toilet and the wall behind the toilet. On 7/16/24 at 11:00 AM, R1 stated, They are cleaning my room daily, but not thoroughly. There is a stain on the toilet floor, and the window curtains have mold. I repeatedly mentioned it to nurses and nursing assistants, and nobody wanted to do anything. R2 is a [AGE] year-old male admitted on [DATE] with mild cognitive impairment as per the MDS dated [DATE].…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-05 · tag F0622 — isolatedNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
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 have physician document the necessity of immediate transfer. This applies to 1 of 5 residents (R4) reviewed for transfer/discharge in a sample of 5. The Findings Include: R4 was a [AGE] year-old male admitted on [DATE], with an admitting diagnosis, including dementia, anxiety, mental disorder, depression, and Alzheimer's. A record review of the clinical progress note, dated 3/14/24, documents R4 was involuntarily discharged to the hospital due to aggressive behavior towards another resident. A record review of the clinical documentation indicates there is no evidence of any physician documentation to reflect the necessity of the transfer on 3/13/24. On 4/5/24 at 12:10 PM, V17 (Nurse Practitioner/Attending) stated, The Psychiatrist is supposed to document the necessity of the immediate transfer. On 4/5/24 at 1:10 PM, V18 (Psychiatrist) stated, When (R4) was immediately transferred to the hospital on 3/14/24, I was unaware of the documentation I should…
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 · Fcited before2024-03-15 · tag F0803 — failed to meet residents' dietary needs — widespreadEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to follow the facility's menu for pureed diets and failed to served the correct serving size for the lunch meal. This failure has the potential to affect all residents residing in the facility. The findings include: The facility's Application for Medicare and Medicaid application, dated 3/11/24, shows the facility census was 141. 1. The facility's Diet Type Report, dated 3/13/24, shows R20, R71, R35, and R67 are on a pureed diet. The facility's Spread Sheet Menu for the lunch meal on 3/11/24 shows pureed stuffed peppers, pureed rice, pureed mixed vegetable, and a purred sugar cookie is to be served for the lunch meal. On 3/11/24 at 11:25 AM, V50, Cook, was plating the meals for the lunch meal. There was no pureed rice on the steam table, nor was pureed rice served to the residents on pureed diets. On 3/21/24 at 12:40 PM, V4, Dietary Manager, said she did not know why the cook did not puree rice for the lunch meal. V4 said rice can be pureed, and the residents on pureed diet should have a grain portion, which 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.
- Potential for harm · F2024-03-15 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 a three compartment sink was maintained at the correct concentration and failed to ensure hair restraints were worn. This failure has the potential to affect all residents residing in the facility. The facility's Application for Medicare and Medicaid dated March 11, 2024 shows the facility census was 141. 1. On 3/11/24 at 9:48 AM, V51 was washing pots, pans, and other various dishes via a three compartment sink. At 10:11 AM, V51 used a test strip to test the sanitation level in the third compartment. The sanitizing solution measure 50 PPM. V51 said it should read 200 PPM. V51 said the water was too cold. V51 said the sanitizing solution won't read properly if the water is too cold. On 3/12/24 at 1:33 PM, V4, Dietary Manager, said the sanitizing solution should ready between 100-200 PPM. The facility's Manual Sanitizing in Three Compartment Sink policy, dated 2017, shows, After washing and rinsing utensils or equipment are sanitized in the third sink by immersion in either: Hot water or chemical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-15 · 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
Based on interview and record review, the facility failed to provide oral care to a resident requiring extensive assistance with activities of daily living (ADLs). This applies to 1 of 32 (R31) reviewed for ADLs in the sample of 32. The findings include: 1. R31's admission Record shows an admission date of 1/24/2024, and a medical diagnosis of Parkinson's Disease. R31's Progress Notes from 1/24/2024 states resident is alert and oriented x3. Progress note states resident needs extensive assistance with ADLs and toileting. R31's Progress Notes from 3/9/2024 state resident's POA came and requested oral care of resident as she is not able to do by herself. Progress notes also state resident is A&O x3 and able to make her needs known. R31's Task: GG - Oral Hygiene, date 3/11/2024, shows no oral hygiene data for 2/17/2024, 2/19/2024, 2/23/2024, and 3/4/2024. R31's Care Plan shows ADL self-care deficit, requiring extensive assist with ADLs related to Parkinson's disease. On 3/11/2024 at 10:45AM, R31 said her teeth haven't been getting brushed regularly. R31 said she would like her teeth…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-15 · 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 staff failed to assess, notify the physician, and implement treatment interventions for a resident with a new skin alteration for 1 of 27 residents (R392) reviewed for quality of care in the sample of 32. The findings include: On 3/11/24 at 2:36 PM, V30 (Assistant Director of Nursing) and V31 (Certified Nursing Assistant) provided care to R392. R392's right lateral knee was reddened and had a dime sized abrasion on it. R392's right lateral ankle had a small abrasion on it. V30 said they could have been from her fall she had a few days earlier. On 3/12/24 at 9:54 AM, V17 (Wound Nurse) observed R392's abrasions on her knee and ankle. V17 said she was not aware of the skin alterations, but she did have a couple of falls, so they are most likely from one of those. V17 said if a staff member notices a new skin alteration, they should report it to the nurse, and the nurse should do an assessment, chart the findings, and notify the physician to get treatment orders. V17 said it should be done as soon as the skin alteration 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 · Dcited before2024-03-15 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure a device was applied to a contracted hand to 1 of 5 residents (R73) reviewed for range of motion in the sample of 32. The findings include: R73's Physician Order Sheet (POS) show R73 has diagnoses that include left sided hemiplegia and hemiparesis due to stroke. R73's facility assessment, dated 1/27/24, shows R73 is alert and oriented and able to verbalize her needs. R73's Restorative Assessment, dated 1/22/24, under functional limitations shows left extremity show with impairment. R73's careplan undated shows, Resident has impaired range of motion related to impaired mobility associated with the disease processes/conditions of hemiplegia and hemiparesis affecting left non-dominant side, pain in left shoulder, and pain in left leg. Resident will maintain range of motion to joints of Left lower extremity and left upper extremity. On 3/11/24 at 9:30AM, R73 was in bed. R73's left hand drawn to her chest with closed fist. R73 said she used to have a splint to her left hand, but it has been missing. R73…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-15 · 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
Based on interview and record review, the facility failed to safely transfer a resident resulting in a fall. This applies to 1 of 4 residents (R75) reviewed for safety in the sample of 32. The findings include: 1. R75's Care Plan lists R75 as having an actual ADL self-care deficit related to impaired cognition, impaired mobility and comorbidities, initiated on 8/21/2019; Interventions include extensive assistance two-person physical assist. On 2/4/2024, R75's Fall record shows R75 had a fall during transfer. On 3/12/2024 at 2:37 PM, V19, Certified Nursing Assistant (CNA), said on 2/4/2024, she was working with R75. V19 said she was transferring R75 in the bathroom by herself with a gait belt. V19 said she stepped back to grab the wheelchair to reposition it while R75 was standing, and R75 started to sit down when the wheelchair wasn't completely behind her. V19 said she assisted R75 down to the floor to keep her from hitting her head. V19 said R75 was a 1 person assist for transfers. On 3/13/2024 at 8:30 AM, V2, Director of Nursing (DON), said 2 person transfers should be completed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-15 · 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
Based on interview and record review, the facility failed to ensure dietary interventions were initiated for 1 of 5 residents (R243) reviewed for significant weight loss in the sample of 27. The findings include: On 3/11/24 at 11:17 AM, R243 said he has lost over 10 lbs at the facility and no one cares. The Dietician came and said I would start getting some shakes, but I haven't seen anything since. I even ordered my own (dietary supplement). A Dietary Note completed on 3/7/24 by V6 (Dietician) shows R243 has a current weight of 80 lbs. (pounds) which is a 25.2% and 27 lb. weight loss over 1 month time. The note lists interventions add two cal 237 milliliters ml. 2 times a day, and proheal 30 ml. three times a day. R243's active Physician Order Summary shows orders for ProMod and TwoCal to start on 3/7/24. On 3/12/24 -R243's Medication Administration Summary did not show ProMod or TwoCal listed. At 12:40 PM, V5 (Licensed Practical Nurse/LPN) said the supplements should be listed in a residents MAR (Medication Administration Record). She pulled up R243's electronic MAR, and said 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 before2024-03-15 · 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 observation, interview, and record review, the facility failed to ensure a residents medication was received from pharmacy for 1 of 27 residents (R136) reviewed for pharmacy services in the sample of 27. The findings include: On 3/12/24 at 8:25 AM, V12 (Registered Nurse/RN) was administering morning medication to R136. She omitted to give him a oral packet of Relyvrio (a sodium based medication to treat liver disease and ALS). R136's Physician Order Summary shows an active order, with a start date of 3/9/24, for Relyvrio Oral Packet 3-1 GM (gram) by mouth 2 times a day for ALS. R136's Medication Administration Summary shows the medication was not given 3/9/24, one dose is initialed as given on 3/10/24, it was not given 3/11/24 or 3/12/24. The signatures are coded as 9 see progress note/ not given. On 3/12/24 at 1:15 PM, V12 said she had not given R136 his Relyvrio that morning because the medication is still not here from pharmacy, and she is not sure if anyone had followed up as to why it was not at the facility. On 3/13/24 at 8:09 AM, V2 (Director of Nursing/DON) said 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 · D2024-03-15 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
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 honor resident food preferences and provide an alternative based on their preferences for 3 of 27 residents (R50, R11 and R242) reviewed for food preferences in the sample of 27. The findings include: 1. On 3/11/24 at 12:15 PM, R50 was in the dining room for lunch. R50 said he wanted a burger and ice cream for lunch instead of what was served to him. V18 (Restorative Licensed Practical Nurse) stated, We ordered you a burger, but I don't know if you can get ice cream. R50 sat at the dining table until 12:50 PM. R50 then propelled himself to his bathroom. At that time, V29 (MDS Coordinator) brought a tray with a burger on it to his room. There was no ice cream on the tray. R50 refused the burger. R50 said he didn't have time to eat the burger because he had to get to his dialysis. At 12:57 PM, R50 was transported to dialysis. On 3/13/24 at 10:31 AM, V18 said she was at R50's table when he requested a burger and ice cream. V18 said she told V24 (Scheduler) to order him a burger. V18 said after it did not come,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-15 · tag F0825 — isolatedProvide or get specialized rehabilitative services as required for a 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 interview and record review, the facility failed to complete an ordered speech therapy evaluation, and failed to offer therapy services to a newly admitted resident. This applies to 2 of 3 (R75, R242) reviewed for speech therapy services in the sample of 32. The findings include: 1. R75's Order Details shows an order for Speech Evaluation dx: possibly aspiration on 12/7/2023. On 3/12/2024 at 10:52AM, V22, Speech Therapy, said she saw R75 in July for a routine screening, but has not seen her since December. V22 said she was unaware of any request for eval. V22 said the therapy computer system does not cross over from the facility's computer system. On 3/13/2024 at 8:30AM, V2, Director of Nursing (DON), said speech evaluations should be completed when they are ordered by a physician. V2 said speech evaluations are normally completed within 24-48 hours. V2 said R75's speech evaluation was missed, and should have been completed. The facility failed to provide a completed speech evaluation prior to 3/13/2024…
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 · D2024-01-03 · tag F0687 — failed to care for feet properly — isolatedProvide appropriate foot care.
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 podiatry recommendations for routine podiatry care for a resident. This applies to 1 of 3 residents (R1) reviewed for foot care in the sample of 5. The findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including arthritis, dementia, Alzheimer's disease, dysphagia, heart failure, and pulmonary hypertension. R1's MDS (Minimum Data Set), dated October 13, 2023, showed R1 had severe cognitive impairment. The MDS continued to show R1 was dependent on facility staff for personal hygiene. Facility documentation showed R1 was seen by the podiatrist on August 8, 2023. The documentation continued to show Follow-up in two to three months or as needed for a more acute problem. Contact [podiatry group] with any concerns. Facility documentation showed the podiatry group provided services in the facility on October 10, 2023, October 30, 2023, December 12, 2023, and December 20,…
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 before2023-06-01 · 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 provide ADL (Activities of Daily Living) care to a resident who requires assistance, and failed to provide two showers a week as ordered. This applies to 2 of 3 residents (R13,R84) in the sample of 26 reviewed for ADL's. The findings include: 1. The face sheet for R13 shows diagnoses to include chronic pulmonary disease, Alzheimer's Disease and cellulitis. The facility assessment dated [DATE] shows R13 to severe cognitive impairment and requires the assistance of staff for all activities of living. On 5/30/23 at 10:35 AM, R13 was observed asleep in bed, with her uneaten breakfast in front of her. R13 was sitting up in bed, on her back. On 5/30/23 at 12:12 PM, R13 was observed in bed on her back, with her lunch tray in front of her. R13 was observed numerous times opening her eyes and attempting to grab her silverware and drinking glass in attempts to feed herself. R13 tipped over her drinking glass onto her plate. On 5/30/23 at 3:07 PM,…
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 before2023-06-01 · 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 identify a pressure injury prior to becoming a stage 2, failed to perform weekly assessments for a pressure injury, and failed to reposition residents with pressure injuries for 2 of 6 residents (R125, R23) reviewed for pressure injuries in the sample of 26. The findings include: 1. R125's admission record documents she was admitted to the facility on [DATE], with multiple diagnoses including Multiple Sclerosis and dementia. The facility's 4/22/23 quarterly assessment shows R125 to have severe cognitive impairment. The same assessment documents she requires extensive assistance with bed mobility and transfers between surfaces. The skin condition assessment shows she is at risk for developing pressure injuries. R125's current care plan documents she is at risk for breakdown in skin integrity related to impaired mobility, impaired cognition, incontinence, and comorbidities including: dementia, MS (Multiple Sclerosis), depression, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-06-01 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to implement restorative therapy interventions. This applies to 1 of 3 (R83) residents reviewed for restorative services in the sample of 26. The findings include: R83's Face Sheet showed an original admission date of 3/30/20, with diagnoses to include: legal blindness; lack of coordination; muscle weakness (generalized); gait and mobility abnormalities. R83's 5/22/23 Nurse Practitioner Note showed R83 is alert and oriented to person, place, and time; however, she can be forgetful at times. On 6/1/23 at 9:07 AM, R83 was in her wheelchair with her walker in the room. R83 was dressed and she was wearing walking shoes. R83 was alert, oriented, and answered questions appropriately. On 6/01/23 at 9:07 AM, R83 stated, They have run through a number of people who run restorative . I would like to eventually walk with a cane .I used to walk to the dining room, but I would do that on my own. I would walk down and back; that was very seldom with staff. R83 said she had been lightheaded with walking; however, it has…
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 before2023-06-01 · 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
Based on observation, interview, and record review, the facility failed to, following a resident's 40 pound weight loss, notify the resident's physician of the registered Dietitians recommendation to increase her tube feeding rate; and failed to re-weigh a resident per the Dietitian's request. This applies to 1 of 8 residents (R27) reviewed for weight loss in the sample of 26. The findings include: R27's admission Record (Face Sheet) showed an original admission date of 5/7/22, with diagnoses to include: paralysis affecting the left side; dysphagia (difficulty swallowing); diabetes type II; stroke; and dementia. On 5/30/23 at 1:54 PM, R27 was in bed laying on her back with the head of her bed at 45 degrees. R27's feeding was running at 45 milliliters per hour. R27 was able to answer yes and no questions via head movement. R27 denied concerns with her tube feeding. On 6/01/23 at 10:14 AM, V16, Licensed Practical Nurse, stated R27 tolerates her current tube feeding. V16 states R27 is on a continuous feeding for 4 hours on then 2 hours off. V16 states she checks for residual (measures…
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 before2023-06-01 · 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 observation, interview, and record review, the facility failed to ensure medications were administered before being signed out, and failed observe a resident to ensure medications were taken for 2 of 6 residents (R53, R13) reviewed for medication administration in the sample of 26. The findings include: 1. On 5/31/23 at 8:25 AM, V13 (Licensed Practical Nurse) was observed during the morning medication pass for R53. V13 dispensed six pills into a medication cup (acetaminophen, omeprazole, glipizide, lisinopril, metoprolol, and pramipexole). V13 documented in R53's electronic medical record that all six pills had been given to the resident. V13 then entered R53's room and gave her the pills to swallow. V13 exited the room and stated she charts the pills as given to the resident before giving them, because she knows R53 well, and she always takes them. V13 said she gives medication that way to all the residents; she knows will take them. V13 said she only waits to sign out medication after giving them if the resident is known to refuse them at times. On 5/31/23 at 9:06 AM, V10…
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 before2023-06-01 · 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 failed to ensure incontinence care was provided in a manner to prevent cross contamination for 2 of 26 residents (R53, R5) reviewed for infection control in the sample of 26. The findings include: 1. R53's facility assessment, dated 5/8/23, showed staff assistance required for personal hygiene and occasionally incontinent of urine and bowel. On 5/30/23 at 10:03 AM, V12 (CNA-Certified Nurse Aide) entered R53's bathroom and donned gloves. R53 stood up from the toilet. Bowel movement was on the toilet rim and in the toilet. R53 had urinated in the toilet. V12 cleansed 53's buttocks and groin area. V12 continued to wear the contaminated gloves to apply a zinc barrier cream to the buttocks. V12 wore the same gloves to put on a fresh brief, pull up her pants, maneuver the wheelchair out of the bathroom, and put the call light near R53. V12 exited the room wearing the contaminated gloves down the hallway. V12 finally disposed of them in the garbage can on the medication cart at the nurses' station. V12 did not perform hand…
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 · D2023-06-01 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to address the pneumonia vaccine for 1 of 5 residents (R28) reviewed for vaccines in the sample of 26. The findings include: R28's Face Sheet, dated 6/1/23, showed R28's original admission date was 9/13/22. R28 had diagnoses to include, but not limited to: diabetes; reduced mobility; unsteadiness on feet; generalized muscle weakness; cognitive communication deficit; vascular dementia; hypothyroidism; bipolar disorder; major depressive disorder; anxiety; insomnia; and spondylosis. R28's facility assessment, dated 4/26/23, showed she had severe cognitive impairment. R28's Immunization Report, printed 6/1/23 at 11:41 AM, did not contain information regarding R28's pneumonia vaccines. R28's Progress Notes did not contain any information regarding R28's pneumonia vaccination status. On 05/31/23 at 3:09 PM, the surveyor requested pneumonia vaccine information for R28. On 6/1/23 at 8:57 AM, V2 (DON - Director of Nursing) said she was unable to find R28's Pneumonia vaccination status in her record. V28 stated, I called [the pharmacy]…
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
$57,365 in federal fines across 2 penalties.
- $18,377 — penalty dated 2024-05-16
- $38,988 — penalty dated 2024-03-15
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 |
|---|---|---|---|---|
| AMSTER, JEREMY | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 49% | since 07/01/2011 |
| MILSTEIN, ARI | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 16% | since 06/18/2013 |
| MILSTEIN, STUART | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 16% | since 07/01/2011 |
| MINKOVE, ELANA | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 16% | since 07/01/2011 |
| SW MANAGEMENT | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/01/2011 |
| HILL, VICTORIA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2013 |
| WOLFE, SHELDON | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/01/2011 |
CMS files one row per role, so the 8 rows in the source record cover these 7 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.
About 86% 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 $1.0M paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145795. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-06, 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.