Alta Rehab At Wauconda
176 Thomas Court, Wauconda, IL 60084 · For profit - Corporation · 149 certified beds · (847) 526-5551 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- lower-than-typical staff turnover (28% vs 45% nationally) — better care continuity
- it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Dec 2024
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 5 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 | 5.9% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.3% | 6.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.3% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 74.8% | 54.2% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.3% | 3.1% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 10.1% | 14.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 10.1% | 18.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 80.0% | 91.8% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 4.9% | 4.8% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 25.3% | 20.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.7% | 21.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.6% | 2.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 52.2% | 63.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 25.1% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 7.2% | 13.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.02 | 2.02 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.27 | 2.22 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
65.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 694 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 37.6% 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 332 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.36 therapist hours per resident per day in 2026Q1 — more than 62% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 26% 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 | 65.0%CMS range 60.4–69.3 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.9%CMS range 10.4–13.9 | 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 | 37.6% | 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 | 53.9% | 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 | 39.2% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 99.7% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 98.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.4% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.3%CMS range 3.6–7.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.86 | 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 149 beds and averages 144.2 residents a day — about 97% occupied, or roughly 5 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.83 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.06 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.19 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.45 hrs/resident/day on weekends vs 3.99 on weekdays — 13% thinner on weekends. RN hours go from 1.16 to 0.79 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 28% is below the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
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.
27 citations, most serious first. The 12 most serious are shown; the remaining 15 are one tap away and print in full.
- Actual harm · Gcited before2024-09-11 · 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 positioned in a safe manner for one of three residents (R1) reviewed for safety in the sample of three. This failure resulted in R1 experiencing a fall which required sutures and resulted in R1 obtaining a small subdural hematoma. The findings include: R1's Face Sheet shows he was admitted to the facility on [DATE], with diagnoses including alcohol abuse, fall from bed, mood disorder, vascular dementia, generalized anxiety disorder, Parkinson's disease, and malnutrition. R1's Fall Risk assessment dated [DATE], shows that R1 is at risk for falls. R1's Significant Change in Status Minimum Data Set, dated [DATE], shows R1 is not cognitively intact, has an impairment on both upper and lower extremities, is dependent (helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity) on staff for toileting, personal…
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 before2023-07-26 · 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 pressure reducing interventions were in place for residents with pressure injuries for 2 of 8 residents (R106, R183) reviewed for pressure injuries in the sample of 28. This failure resulted in R106's coccyx excoriation progressing to an unstageable pressure injury and R183's Stage 3 coccyx pressure injury advancing to an unstageable pressure injury. The findings include: 1. On 07/24/23 at 10:34 AM, R106 was in her room, sitting up in her wheelchair on a flattened pillow. R106 said she has a dressing on the sore on her bottom. R106 said the wound doctor comes, but her wound is not getting better. R106 said the wound doctor did a procedure the last time and her bottom is very inflamed and burns. R106 did not have a pressure reducing cushion in her wheelchair or a pressure reducing air mattress on her bed. On 07/24/23 at 12:57 PM, R106 was sitting in her wheelchair in the dining room on a flattened pillow. R106's Most Recent Skin…
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 · D2026-03-19 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to determine the residents' wishes upon admission for advanced directives. This applies to one of three residents (R1) in the sample of seven reviewed for advanced directives.The surveyor confirmed by observation, interview and record review that the deficiency practice occurred on [DATE] and was corrected on [DATE], prior to the start of this survey and was therefore past noncompliance.The findings include:The facility face sheet for R1 shows she was admitted to the facility on [DATE] and discharged on [DATE]. The diagnoses for R1 include but are not limited to metabolic encephalopathy, urinary tract infection and Type 2 Diabetes Mellitus. The section of the face sheet for advanced directive is blank. The admission observation form dated [DATE] shows R1 was alert and orientated to person, place, time and situation.A nursing note dated [DATE] shows R1 was admitted to the facility with altered mental status and was alert and oriented but was forgetful. No…
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 before2026-01-17 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to communicate and document a fall incident in a timely manner, failed to a complete a post fall assessment or perform any subsequent assessments following a fall, and failed to implement interventions to prevent any future incidents. This failure affects one of three residents (R1) reviewed for falls in the sample of 3.The findings include:R1's face sheet documented an admission date of 01/06/2026 from an acute care hospital where she was hospitalized from [DATE] through 01/06/2026. Her past medical history upon admission included but not limited to seizures, anemia, hypertension, anxiety, osteoarthritis to left wrist, and chronic kidney disease. (Review of R1's census record indicates she is on hospital leave.)R1's fall risk assessment with effective date 01/06/2026 (same day as admission) documented score of 8 which indicated R1 is not at risk for falls. Assessment with effective date of 01/08/2026 (signed on 01/16/2026) documented score of 14 and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-30 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident was free from verbal abuse for 1 of 3 residents (R1) reviewed for abuse in the sample of 4. The findings include: The facility's Incident Report for R1 shows on 12/23/24 resident was overheard in the dining room (during breakfast) stating that she was abused by a CNA (certified nursing assistant) on the previous day. Social Service Designee interviewed the resident who claimed that the day before she overheard a CNA and an Activity Aide arguing in the hallway. According to the resident, she tried to intervene and tell them to stop, and the CNA allegedly pointed her finger in the resident's face and used profanity at her. On 12/30/24 at 9:47 AM, R1 was in her room re-arranging her things on her bed. R1 stated on 12/22/24 after breakfast, she heard yelling in her hall. R1 stated she went out of her room and as she got closer to the people yelling, she saw V6 Certified Nursing Assistant (CNA) was yelling at V5 Activity Aid.…
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 · D2024-12-30 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to thoroughly investigate an allegation of abuse for 1 of 3 residents (R1) reviewed for abuse in the sample of 4. The findings include: The facility's Incident Report for R1 shows on 12/23/24 resident was overheard in the dining room (during breakfast) stating that she was abused by a CNA on the previous day. Social Service Designee interviewed the resident who claimed that the day before she overheard a CNA and an Activity Aide arguing in the hallway. According to the resident, she tried to intervene and tell them to stop, and the CNA allegedly pointed her finger in the resident's face and used profanity at her. On 12/30/24 at 9:20 AM, V1 Administrator said the incident was determined to be a 2 staff verbal altercation witnessed by R1. V1 said the initial report said R1 used profanity at her, but as they interviewed staff, the profanity was toward the other staff and not the resident. V1 said they did not substantiate abuse. On 12/30/24 at 9:47 AM, R1 was in her room re-arranging her things on her bed. R1 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 · Dcited before2024-12-09 · 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 observation, interview, and record review the facility failed to ensure a resident was transferred in a safe manner for 1 of 3 residents (R2) reviewed for safety in the sample of 3. The findings include: On 12/9/24 at 12:55 PM, R2's room had handwritten signs above her bed and on the wall by the bathroom that said, Fall Risk, Use Gait Belt. On 12/9/24 at 12:57 AM, R2 was sitting in her wheelchair at the dining room table. R2 stated when she first got to the facility she walked to the bathroom with her walker. R2 stated when she was coming out of the bathroom, V13 Certified Nursing Assistant (CNA) was with her, and she started to fall. R2 stated V13 assisted her to the floor. R2 stated V13 did not put a gait belt on her. R2 stated they should use a gait belt, now I make sure! On 12/9/24 at 1:34 PM, V13 stated R2 had walked with the walker to the bathroom by herself. V13 stated she assisted R2 to walk out of the bathroom with the walker and R2's legs got weak. V13 stated she assisted R2 to the floor. V13 stated she was holding R2's pants and did not have a gait belt on R2. 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 before2024-11-04 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to assess and monitor a resident after a fall for 1 of 3 residents (R1) reviewed for quality of care in the sample of 3. The findings include: R1's Final Incident Report shows that R1 had an assisted fall on 10/11/14. R1 had an X-ray done on 10/14/24 that showed an acute nondisplaced oblique distal radial fracture with soft tissue swelling. On 11/4/24 at 9:19 AM, R1 was sitting in her wheelchair in her room. R1 had a brace on her left wrist and was unable to move her left arm. On 11/4/24 at 9:19 AM, R1 stated that she had a fall in the bathroom. R1 stated that she must have hit her left arm on the wheelchair when she fell. R1 stated that after she fell, the nurse came in and helped her back up into the wheelchair. R1 stated that it did not appear that the nurse did any type of assessment after the fall. R1 stated that she had pain and tingling in her left arm right after the fall. On 11/4/24 at 1:32 PM, V6 (Registered Nurse) stated that she was the nurse on duty when R1 fell. V6 stated that she was alerted by 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 · D2024-08-21 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to notify a physician prior to and after holding a blood pressure medication. This applies to 1 of 27 residents (R84) reviewed for notification of changes in the sample of 27. The findings include: R84's August 2024 Medication Administration Record (MAR) shows, Hydrochlorothiazide 12.5 mg (milligrams), give 1 tablet by mouth one time a day related to essential hypertension (high blood pressure) and Lisinopril 20 mg tab, give 1 tablet by mouth one time a day related to essential hypertension. The same report shows, both medications were held on August 1st, 5th & 18th, 2024. R84's electronic medical record shows, her physician was not notified on August 1st, 5th or 18th, 2024 of her blood pressure medication being held. On August 19,2024 at 10:17 AM, V16 LPN stated, whenever they hold a medication, they contact the doctor and let them know. The facility's physician-family notification-change in condition dated November 13, 2018 shows, Purpose: To ensure that medical care problems are communicated to the attending physician or…
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 before2024-08-21 · 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 implement pressure ulcer prevention interventions for a resident who is at risk for developing pressure ulcers for 1 of 5 residents (R9) reviewed for pressure ulcers in the sample of 27. The findings include: On 8/19/24 at 10:12 AM, R9 was laying in bed. R9 did not have blankets on and R9's heels were observed directly on her mattress (not a low air loss mattress). R9 stated that she is not sure if she has wounds on her heels or not, but they are a little tender. R9 also stated that she is supposed to wear pressure relieving boots but sometimes they do not put them on. R9's pressure relieving boots were sitting in the chair in R9's room. At 11:45 AM, R9's heels were still directly on the bed and her boots were still in her chair. On 8/20/24 at 1:03 PM, V20 (Wound Registered Nurse) stated R9 is at risk for developing pressure ulcers and should have her heels offloaded to prevent pressure ulcers. V20 stated that R9's heels should not 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 · D2024-08-21 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow occupational therapy recommendations for a resident with a contracted hand. This applies to 1 of 4 residents (R70) reviewed for range of motion/restorative in the sample of 27. The findings include: R70's face sheet lists his diagnoses to include hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. On August 19, 2024, at 10:30 AM, R70 was lying in bed. All 4 of his fingers were bent in a fist like shape on his right hand. He stated, he can open his fingers some but not all the way. His hand was not like that when he came to the facility and has gotten worse. He tries to do hand exercises. The facility does not do any exercises/anything with his hand. On August 20, 2024, at 9:20 AM, R70 was lying in bed. His hand was in the same position as the day before. On August 21, 2024, at 9:34 AM, V17 Occupational Therapy (OT) Assistant stated, R70 has a non-fixed contracture to his right hand. They were…
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 before2024-08-21 · 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 safely transfer a resident by preventing the resident's head from hitting the mechanical lift, failed to safely transport a resident and failed to update a resident's care plan after a fall. This applies to 2 of 27 residents (R19 and R5) reviewed for safety in the sample of 27. The findings include: 1. R19's Face Sheet showed R19 was a [AGE] year-old female with the diagnoses of dementia and anxiety. On 08/19/24 at 10:10 AM, R19 was sitting in her wheelchair. R19 had bruising to the left side of her forehead. The bruising started at R19's hairline and extended down to her left eyebrow. The bruising was about the width of R19's eyebrow/eye. The bruised area had a darker purple area about the size of a quarter near R19's hairline. R19's Skin- Other Skin Condition Report dated 8/14/24 showed R19 hit her forehead on a mechanical lift resulting in a red area to R19's forehead and ice was applied. On 08/20/24 at 09:01 AM, V4 (Certified Nursing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 15 citations
- Potential for harm · Dcited before2024-08-21 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure a resident received their routine medication for 1 of 27 residents (R2) reviewed for pharmacy services in the sample of 27. The findings include: A facility assessment done on 6/14/24 showed R2's cognition was intact. R2's Order Summary Report showed R2 had an order for morphine (pain medication) to be given three times a day scheduled for pain. On 08/19/24 at 09:45 AM, R2 said the facility ran out of her morphine because they did not reorder the medication in time. R2 said she missed two doses of the morphine. R2's August 2024 Medication Administration Record (MAR) showed she was to receive morphine at 5:00 AM, 1:00 PM and 9:00 PM. The MAR showed on 8/5/24 R2 was not given her 1:00 PM or 9:00 PM doses. V5 (Licensed Practical Nurse- LPN) was the nurse that documented R2 did not received the 8/5/24 1:00 PM dose. On 08/19/24 at 11:57 AM, V5 could not recall why R2 did not receive her scheduled morphine. A progress note entered by V5 dated 8/5/24 at 1:36 PM, 36 minutes after the 1:00 PM dose of morphine was due, that 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.
- Potential for harm · D2024-08-21 · 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 ensure residents receiving a pureed diet received a 5.33-ounce (oz) portion of the pureed stuffed shells. This applies to 2 of 2 residents (R390, R81) reviewed for pureed diets in the sample of 27. The findings include: Facility provided Diet Type report dated 8/19/24 shows that R390 and R81 receive a pureed diet. On 8/19/24 at 11:31 AM, V11 (dietary aide) began to check temperatures and prepare for the lunch service on the 500, 600, and 700 units. V11 asked V12 (dietary aide) to grab the pureed meals and a few requested alternates from the kitchen. V12 returned from the kitchen at 11:45 AM with three pre-plated puree plates that were wrapped and covered along with the requested alternate items. On 8/19/24 at 11:53 AM, V12 removed the cover to the first puree plate which included a pre-plated serving of pureed stuffed shells and a pre-plated serving of pureed zucchini already on the plate. V12 then scooped a serving of mashed potatoes and gravy onto the plate before handing it to the nursing staff. 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 · D2024-06-17 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure a resident's opioid pain medication was administered as prescribed to avoid a significant medication error. This failure applies to 1 of 4 residents (R1) reviewed for medication administration errors in the sample of 4. The findings include: The Facility Reported Incident Report dated 6/4/24 showed, On 6/3/24 at approximately 11:30 AM, the patient (R1) was seen by the NP (nurse practitioner) due to increased confusion. Nurse continued to monitor the patient, reviewed his meds (medications), and noted that Norco 10/325 (opioid pain medication) PO (by mouth) 1 tablet was given 3 hours from last dose. Patient has an order for Norco 10/325 1 tablet PO every 6 hours as needed for pain. NP was notified and gave an order for 1x (on time) dose of Narcan (medication to reverse the effects of opioids) and if no improvement of mental status to send to a (local emergency room) . The report showed no significant change in R1's mental state after he was administered Narcan. R1 was sent to a local hospital for an evaluation. R1 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 · Ecited before2024-04-10 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to supervise residents receiving medications and failed to administer medications as ordered for seven of ten residents (R1, R2, R3, R7, R8, R9, R10) reviewed for medication administration in the sample of ten. The findings include: 1. R10's admission Record shows she was admitted to the facility on [DATE], with diagnoses including unspecified right bundle branch block, constipation, cellulitis of right lower limb, unstable angina, edema, asthma, hypertension, and pain. R10's Weights and Vitals summary shows R10's blood pressure was 120/54. R10's pulse is not documented. R10's Order Summary Report shows an order for losartan 100 mg (milligrams) one time daily related to high blood pressure hold if blood pressure is less than 110/60. R10's Order Summary Report shows an order for metoprolol succinate 50 mg ER (Extended Release) one time a day related to high blood pressure. There are no parameters for when to hold the metoprolol. R10's Order…
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 · D2024-01-16 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 contact a resident's legally appointed state guardian prior to transfer to the local hospital for emergency purposes. This applies to 1 (R1) of 3 residents reviewed for hospital transfers in the sample of 3. The findings include: R1's Face sheet dated 1/16/24 shows R1's emergency contact is V6 (R1's Family Member). No additional emergency contacts are listed. R1's signed Order Appointing Plenary Guardian form dated 10/25/23 shows R1 was under the guardianship of a state guardian. On 1/16/24 at 10:05 AM, V1 (Administrator) stated prior to R1's admission to the facility, R1 was noted to have signs of neglect at the hospital while previously residing at home with V6. On 1/16/24 at 12:00 PM, V5 (Director of Social Services) stated V5 was notified R1 would require state guardianship and worked with V1 and V3 (Former Business Office Manager) to complete and file documentation for R1's legally appointed guardianship. On 1/16/24, at 10:15 AM, V3 stated V3 received R1's signed Order Appointing Plenary Guardian form on 11/2/23 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 · Fcited before2023-11-21 · tag F0755 — failed to provide safe pharmacy services — widespreadProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to have a system in place to reconcile all controlled substances from receipt to disposal; failed to complete documentation for receipt of a controlled substance; and failed to properly store narcotic medications for 3 of 3 residents (R1, R4, and R5) reviewed for pharmacy services in the sample of 7. The findings include: 1. The facility's Incident Report dated 11/10/23 showed, On 11/10/23 at approximately 4:30 AM, a (local police officer) called the facility to confirm that employee [V9 - Registered Nurse (RN)] works at the facility. The police officer informed the nurse supervisor that [V9 - RN] is in their custody as he was pulled over in (another town) around 2:00 AM and was found with a bottle of Lorazepam that belongs to resident [R1] in his possession. The officer arrived in the facility around 4:30 AM to hand over the med cart keys that were in the employee's possession. A narcotic count was done throughout the facility and all…
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 · D2023-11-21 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to protect a resident from misappropriation of her controlled medication for 1 of 3 residents (R1) reviewed for misappropriation in the sample of 7. The findings include: The facility's Incident Report dated 11/10/23 showed, On 11/10/23 at approximately 4:30 AM, a (local police officer) called the facility to confirm that employee [V9 - Registered Nurse (RN)] works at the facility. The police officer informed the nurse supervisor that [V9 - RN] is in their custody as he was pulled over in (another town) around 2:00 AM and was found with a bottle of Lorazepam that belongs to resident [R1] in his possession. The officer arrived in the facility around 4:30 AM to hand over the med cart keys that were in the employee's possession. A narcotic count was done throughout the facility and all narcotics were accounted for except the medication that was found in the possession of the employee. The resident did not miss a dose . The employee was newly hired on 10/3/23…
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 before2023-08-07 · 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 transferred safely while using a mechanical lift for 1 of 3 residents (R1) reviewed for safety in the sample of 3. The findings include: R1's Minimum Data Set assessment dated [DATE] shows that she is totally dependent on two staff members for transfers. R1's Care Plan shows, Dependent for transfer using Hoyer lift (mechanical lift). R1's Nursing Notes dated 7/28/23 at 6:58 AM shows, CNA (Certified Nursing Assistant) informed writer to assess patient due to patient hitting head during Hoyer lift transfer at 6 AM. Bruising and minimal swelling noted to R (right) side of forehead. On 8/7/23 at 1:47 PM, V6 (CNA) said that on 7/28/23 she was transferring R1 from her bed to the wheelchair using a mechanical lift. V6 said that when she went to place R1 into the chair, the machine and chair moved causing the cross bar on the mechanical lift to hit R1 in the forehead. V6 said that it was only her in the room doing the transfer by herself…
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 before2023-07-26 · 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 final cooking temperatures were obtained, foods were covered in the freezer to prevent freezer burn, refrigerated foods were labeled when received, a refrigerator on the nursing unit was being monitored for safe temperatures, prepared egg salad was discarded within six days, the high temperature dishwasher was verified for accurate temperature with a paper thermometer, and employee food was not stored in the refrigerator with food for resident use. These failures have the potential to affect all 140 residents residing in the facility. The findings include: The facility's Resident Census and Conditions of Residents (CMS-672) form filled out and dated 7/24/23 by the Corporate Consultant, V3, shows the total number of residents residing in the facility is 140. During the kitchen inspection on Monday, 7/24/23 at 9:37 AM, a shallow pan of corn dogs and wings dated 6/19/23 was stored on a high shelf under a pipe in the walk-in freezer. The food was only partially covered with plastic wrap. V4, Dietary…
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 · D2023-07-26 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure nutritional supplements were supplied for residents with weight loss for 2 of 8 (R15, R25) reviewed for weight loss in the sample of 28. Findings include: 1. R15's face sheet printed on 7/25/23 showed diagnosis to include but not limited to severe protein-calorie malnutrition. R15's physicians order sheet printed on 7/25/23 showed Super cereal at breakfast, boost pudding at lunch and dinner and ensure three times a day with meals. R15's care plan printed on 7/25/23 showed prepare/serve the nutritional diet as ordered. Prescribed diet is .container of boost pudding at lunch, magic cup at dinner, super cereal at breakfast . Provide dietary supplements as ordered . R15's minimum data set (MDS) dated [DATE] showed weight loss, 2. Yes, not on physician-prescribed weight-loss regimen. R15's dietary progress notes dated 3/10/23 at 10:59 AM showed .super cereal at breakfast, boost pudding at lunch, magic cup at dinner, ensure three times 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.
- Potential for harm · Fcited before2022-06-16 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the temperatures in 2 refrigerators did not exceed 41 degrees Fahrenheit, failed to ensure milk did not exceed the expiration date and failed to date a pasta salad after opening. This has the potential to affect all residents in the facility. The findings include: The CMS (Centers for Medicare and Medicaid Services) 672 (Resident Census and Condition) dated 6/14/22, shows the facility census to be 98 residents. On 6/14/22 at 10:30 AM, during the initial kitchen tour, a 3-door refrigerator (Frig #1) was 66 degrees Fahrenheit (F). The refrigerator next to it (Frig#2) was 50 degrees F. During the same tour, a crate of 1/2 pint cartons of chocolate milk had an expiration date of 6/11/22 and a crate of 2% white milk with an expiration date of 6/12/22. An opened, half empty container of macaroni salad had no open date on it. V6 DM (Dietary Manager) took it out and threw it away. V6 Dietary manager stated all opened foods should be dated.…
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 · D2022-06-16 · 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 resolve resident grievances for three of three residents (R14, R36 and R5) reviewed for grievances in the sample of 22. The findings include: 1. On 6/14/22 at 12:49 PM, V12 (R14's daughter) stated R14 has been missing clothing in the past and has never been reimbursed for it. V12 stated she has told CNAs (Certified Nurse Aides) and gave the front desk staff a list of the missing items. V12 stated nothing ever happens. V12 stated it isn't a onetime thing and it happens every time she is admitted to the facility. V12 stated some were brand new with tags still on them. R14 was lying in bed with her eyes closed throughout the interview. When the subject of missing clothing was discussed, R14 opened her eyes wide and clearly stated, Yes, I had my favorite red nightgown that was brand new. It got lost and I have never seen it since. V12 stated no one has ever followed up on the missing items. 2. On 6/14/22 at 12:04 PM, R36 stated the laundry department keeps losing her clothes. I got new items around Christmas and my birthday.…
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 before2022-06-16 · 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 implement interventions to prevent falls for a resident with history of falls. This applies to 1 of 5 residents (R15) reviewed for falls in the sample of 22. The findings include: R15's 6/15/22 Resident Face Sheet showed she was admitted to the facility on [DATE] with diagnoses to include dementia, leg pain, and kidney disease. R15's 3/31/22 Minimum Data Set (MDS) showed severe cognitive impairment with a Brief Interview for Mental Status score of 3 out of 15. The MDS showed she was totally dependent upon two staff members for transfers as well as toileting. The MDS also showed she required extensive assistance of one staff member for dressing and eating. R15's Care Plan showed she had a fall out of bed on 2/23/22 at approximately 9:00 PM. The care plan showed she attempted to get up from bed and slid from her bed to the floor. On 6/14/22 at 11:05 AM, R15 was pleasant but confused. She was laying on her back in bed and she was dressed in 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.
- Potential for harm · D2022-06-16 · 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 urinary drainage bag was kept off the floor for 1 of 2 residents (R250) reviewed for catheters in the sample of 22. The findings include: On 6/14/22 at 1:55 PM, R250 was lying on an air bed, positioned with pillows. R250's urinary drainage bag was lying on the floor, next to her bed. V11 (R250's Spouse) stated he had been visiting for several hours and the catheter bag had been on the floor since he arrived. R250's catheter was draining yellow urine. On 6/14/22 at 2:09 PM, V10 (Registered Nurse - RN) walked into R250's room and stated, That should not be on the floor. (As she picked up R250's catheter bag). V10 asked V11 if he had bumped the catheter bag. V11 stated, No, it's been like that since I got here. V10 (RN) stated the catheter bag should never be on the floor because it is an infection control issue. V10 stated, We don't want to increase the risk of a UTI (urinary tract infection). R250's Face Sheet dated 6/15/22 showed…
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 · D2022-06-16 · 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 wear personal protective equipment. This applies to 1 of 4 residents (R66) reviewed for infection control in the sample of 22. The findings include: R66's Face Sheet showed an admission date of 12/2/22 with diagnoses to include blood infection, dementia, and colitis. On 6/14/22 at 12:26 PM, V4 Registered Nurse (RN) was sitting at dining table on the locked memory care unit. V4 was sitting at a table with R66. V4 had her mask pulled down below her chin and she was eating a grilled cheese sandwich. R66 was not wearing a mask and V4 was providing feeding assistance. R66 took his food without complaint. On 6/14/22 at 12:44 PM, there were two plates of food in front of V4. V4 stated one was for R66 and the other was for herself. (V4's plate had the crust from a grilled cheese and scalloped potatoes remaining.) On 6/15/22 at 2:00 PM, V5 Licensed Practical Nurse stated, We use to be able to eat with the residents to encourage them to eat but normally we don't. He (R66) needs feeding assistance and coaxing. I feed him…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to APERION CARE — 33 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 1.9 | +3.1 vs chain |
| Health inspection | 4 of 5 | 2.0 | +2.0 vs chain |
| Staffing | 3 of 5 | 1.6 | +1.4 vs chain |
| Quality measures | 5 of 5 | 3.3 | +1.7 vs chain |
The other 32 homes this chain runs (chain average 1.9★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| LAN 3 OP LLC | Organization | DIRECT OWNERSHIP INTEREST | — | since 11/13/2023 |
| APERION CARE EXEC HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 15% | since 11/13/2023 |
| LAN 3 INVESTOR GROUP LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 20% | since 03/01/2024 |
| GOLDFARB, BRIAN | Individual | INDIRECT OWNERSHIP INTEREST | — | since 11/13/2023 |
| ULBERT, LISA | Individual | INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/13/2023 |
| ANCONA, CECILA | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2024 |
| SIRICHANA, TIFFANY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2024 |
| FRANKEL, FREDERICK | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 01/01/2024 |
| SPECTOR, JENNIFER | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2024 |
| APERION CARE INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2024 |
| BERNETT, SANDRA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2024 |
| FARAH, BEHZAD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2024 |
| TUROFSKY, STEVEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2024 |
| WILHELM, NAFTALI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2024 |
| BERKOWITZ, DAVID | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 03/18/2025 |
| MEYSTEL, YOSEF | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 03/18/2025 |
| 176 THOMAS COURT, LLC | Organization | ADP OF THE SNF | — | since 03/17/2025 |
| APERION CONSULTING, LLC | Organization | ADP OF THE SNF | — | since 03/01/2024 |
| CURIS SERVICES LLC | Organization | ADP OF THE SNF | — | since 03/01/2024 |
| DAVID A BERKOWITZ DELTA TRUST | Organization | ADP OF THE SNF | — | since 03/01/2024 |
| JOSHUA HOFFMAN TRUST | Organization | ADP OF THE SNF | — | since 11/13/2023 |
| YOSEF MEYSTEL DELTA TRUST | Organization | ADP OF THE SNF | — | since 03/01/2024 |
CMS files one row per role, so the 40 rows in the source record cover these 22 parties — each is shown once here with every role it holds. Nothing is omitted.
10 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $2.1M paid to related parties — landlords or management companies under common ownership — equal to about 10% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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.
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 145887. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-08-21, 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.