Aspyre of Waukegan
1615 Sunset Avenue, Waukegan, IL 60087 · For profit - Corporation · 115 certified beds · (847) 244-6700 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- lower-than-typical staff turnover (26% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2024
- inspectors cited 3 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (37) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $135,606 in federal fines (most recent 2026-04-13)
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (2/5)
- 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 | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 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 | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 2 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 1 to 2 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 | 19.7% | 13.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 6.0% | 6.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.0% | 0.9% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 8.5% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 91.9% | 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 | 5.7% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 25.9% | 14.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 8.7% | 18.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.8% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 20.3% | 20.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.2% | 21.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 70.8% | 63.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 37.8% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 16.4% | 13.9% | 12.0% | 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.
Met the expected recovery: 56.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 23 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 0.25 therapist hours per resident per day in 2026Q1 — more than 35% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 25% 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.8%CMS range 7.5–16.7 | 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 | 56.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 56.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 60.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | 0.0% | 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 | 5.3% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.96 | 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 115 beds and averages 74.8 residents a day — about 65% occupied, or roughly 40 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.15 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.88 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.84 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.71 hrs/resident/day on weekends vs 3.33 on weekdays — 18% thinner on weekends. RN hours go from 0.97 to 0.67 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 26% is below 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 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.
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.
37 citations, most serious first. The 14 most serious are shown; the remaining 23 are one tap away and print in full.
- Immediate jeopardy · Jcited before2026-04-13 · 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 supervise a resident with dementia, poor safety awareness, and known exit seeking behaviors resulting in the resident eloping from the second floor of the facility through an alarmed door, walking down 14 interior steps, and going out a second alarmed door that led outside. R1 proceeded down 4 concrete steps, onto a wooden deck, turned right, and went down a wooden ramp, across the facility's parking lot, then crossed a busy 4 lane street. R1 then walked through another parking lot of an apartment complex and was found unresponsive (deceased ) near the back of the apartment building approximately 125 yards from the facility's emergency exit door on 4/8/26. This applies to 1 of 6 residents (R1) reviewed for safety and supervision in the sample of 12. The Immediate Jeopardy began on 4/8/26 when R1 eloped from the facility. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 4/10/26 at 4:24PM. The surveyor confirmed…
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 · Jcited before2026-02-25 · 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 ensure a resident received a higher level of care for a resident experiencing respiratory distress. This delay in medical intervention resulted in R77's death. This applies to 1 of 21 residents (R77) reviewed for care and services in the sample of 21.The Immediate Jeopardy began on [DATE] when the resident (R77) was found having respiratory distress and died the same day.V1 (Administrator) was notified of Immediate Jeopardy on [DATE] at 2:45 PM. This surveyor confirmed by interview and record review that Immediate Jeopardy was removed on [DATE] 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:R77's electronic face sheet shows R77 has diagnoses that include, Chronic Obstructive Pulmonary Diseases, (COPD), Congestive Heart Failure, vascular dementia and diabetes.R77's Physician Order Sheet (POS) dated 1/2026 shows R77 has an order of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · Jcited before2023-09-26 · 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 ensure a resident (R1) was free from sexual abuse from a resident (R2) with known sexual behaviors. This failure resulted in R1 being sexually abused by R2. These failures apply to 1 of 9 residents (R1) reviewed for abuse in the sample of 9. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy started on 9/6/23 when R2 with a known history of sexually inappropriate behaviors started displaying inappropriate sexual behaviors and the facility failed to put interventions in place, and to notify his physician or nurse practitioner of the behaviors. This led to R2 behaviors escalating and R2 sexually abusing R1. V2 (Director of Nursing/DON) was notified of the Immediate Jeopardy on 9/25/23 at 2:00 PM. This surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 9/26/23, however, noncompliance remains at a Level 2 because additional time is needed to evaluate the implementation 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.
- Actual harm · Gcited before2026-02-25 · 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
Based on observation, interview and record review the facility failed to identify and assess a pressure ulcer prior to developing a new unstageable pressure ulcer and failed to implement pressure relieving interventions for a resident at risk for developing pressure ulcers. This failure resulted in R59 developing an unstageable pressure ulcer to her right ischium. This applies to 1 of 6 residents (R59) in the sample of 21 reviewed for pressure injuries. The findings include: R59's face sheet shows she has diagnoses including type 2 diabetes, unspecified dementia, hypertensive heart disease, dysphagia and bilateral hearing loss. On 2/22/26 at 9:51 AM, V10 (Licensed Practical Nurse-LPN) said R59 has an open area to her right buttock with a foam dressing. On 2/22/26 at 1:36 PM, R59 was sitting in her reclining wheelchair with no pressure relieving cushion. R59 was thin and underweight. She was yelling out, help me, help me. V10 and V23 (Certified Nursing Assistant) transferred her with the mechanical lift to her bed and provided incontinence care. A foam dressing was in place to her…
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 before2026-02-25 · 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 that dishware and utensils were sanitized prior to use, failed to safely store open lunch meat in the refrigerator, failed to store bulk item scoops in a sanitary manner and failed to ensure hands were washed before preparing food items. This applies to all 77 residents who reside at the facility. The findings include:The Resident Roster provided on 2/22/26 shows that there are 77 residents residing at the facility. On 2/22/26 at 9:42 AM, V5 (Cook/Dietary Aide) was using the dishwasher. V5 tested the chemical dishwasher with a test strip and it was not reading any chemical concentration. V5 tested it multiple times with the same results. V5 then primed the lines and tested again with a different set of test strips with the same results. V3 (Dietary Manager) then tested with the same results and said that she would have maintenance come and look at it. On 2/22/2026 at 9:58 AM, V5 put the dish rack of plate covers and trays away that had just been ran through the dishwasher. V5 continued to use 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 · Fcited before2026-02-25 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 have a Water Management Plan that includes an assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread, control measures to prevent the growth of opportunistic waterborne pathogens and a system to monitor the control measures. The facility also failed to ensure residents with wounds and an indwelling urinary catheter were placed on Enhanced Barrier Precautions and facility staff failed to remove their gloves and wash their hands to prevent the spread of infection. This applies to all 77 residents residing at the facility.The findings include: 1.The Resident Roster provided on 2/22/26 shows that there are 77 residents residing at the facility. The facility provided a two page document that was titled Water Management Program. The document shows, The Water Management Program: Identifies building water systems for which legionella control measures are needed. Assesses how much risk the hazardous conditions in those water systems pose. Applies control measures 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.
- Potential for harm · E2026-02-25 · tag F0688 — failed to keep residents mobile / prevent decline — patternProvide 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 ensure residents with limited range of motion had splints in place for 4 of 12 residents (R63, R6, R16, R32) reviewed for range of motion in the sample of 21.The findings include: 1. On 2/22/26 at 9:52 AM, R63 was reclined back in his chair, his left hand was curled inward indicating he had a contracture to the hand. There were no splints or braces on his hands or legs. R63 was also observed at 11:30 AM, 11:44 AM and 12:40 PM and he did not have splints on. R63's face sheet shows he has diagnoses including aphasia, hemiplegia and hemiparesis following a cerebral infarction and has contractures to the left knee, left elbow, left shoulder and left hand. R63's Physician Order Summary shows an active order for him to have a left hand and elbow brace on for 4 hours on with morning care, and off at lunch time. R63's restorative charting for February 2026 shows the facility should apply R63's splints as ordered. On 2/23/26 at 12:18 PM, V11…
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 before2026-02-25 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure medications were stored in a locked area, failed to ensure medications were stored in a manner to not compromise the integrity of the medication and failed to have schedule II controlled substances double locked. This applies to 5 of 5 residents (R29, R13, R48, R50 and R64) reviewed for medication storage in the sample of 21. The findings include:On 2/22/26 at 11:51 AM, the medication room on the first floor was not locked. There was a bag of fluconazole tablets on the counter in the room. The refrigerator was not locked and contained multiple insulin pens for R29, R13 and R48 and a box of Trulicity for R50. There was a container in the refrigerator containing an insulin pen for R50, a box of acetaminophen suppositories and a box of bisacodyl suppositories for R64. The container had a 1/4 inch of liquid in the bottom of it and the boxes were saturated. On 2/22/26 at 1:07 PM, The second floor west medication cart was reviewed. The narcotic box inside of the cart was not locked and was able to be opened…
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 · E2026-02-25 · 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 — the official record, unedited, may be distressing
Based on observation, interview and record review the facility failed to ensure the pureed rice was in the form to meet the resident's needs for 6 of 6 residents (R5, R23, R37, R39, R49 and R64) reviewed for pureed diets in the sample of 21. The findings include:The facility's Diet Type Report printed on 2/23/26 shows that R5, R23, R37, R39, R49 and R64 are on pureed diets.2/22/26 at 12:55 PM, a pureed diet tray was sampled. The pureed rice was very thick and had chucks of rice throughout. At 12:57 PM, V3 (Dietary Manager) tasted the pureed rice. V3 was observed chewing the rice. V3 said that the rice was not the right consistency. V3 said that it was too gritty. V3 said that pureed food should be smooth like baby food and not have chunks in it. The Facility's Pureed Diet Sheet shows, A Pureed diet is food with a very smooth consistency or foods that have been well processed in a food processor or blender to a very smooth consistency or texture. No solid pieces or parts can be noticed in the food.
- Potential for harm · D2026-02-25 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — the official record, unedited, 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 PASRR (Preadmission Screening and Resident Review) was completed after a Serious Mental Illness (SMI) diagnosis change for 1 of 6 residents (R4) reviewed for PASRR in the sample of 21. The findings include:R4's face sheet shows she was admitted to the facility on [DATE] with a primary diagnosis of Hemiplegia affecting the left side. A diagnosis of schizoaffective disorder was added to her diagnoses on 12/13/19. A PASRR screening was requested from the facility by this surveyor and what was provided was an Interagency Certification of Screening Results (OBRA) dated 5/13/19 and does not identify R4 as having a SMI diagnosis.On 2/23/2026 at 1:24 PM, V1 (Administrator) said the PASRR for R4 was ordered to be done today. The facility provided PASRR screening policy dated 8/2022 shows that a PASRR level 2 should be completed if a resident has a SMI diagnosis.
- Potential for harm · D2026-02-25 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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 PASRR (Preadmission Screening and Resident Review) was completed for a resident with a SMI (Serious Mental Illness diagnosis for 1 of 6 residents (R54) reviewed for PASRR in the sample of 21.The findings include: R54's face sheet shows he was admitted to the facility on [DATE] with diagnoses including Other Schizophrenia, Major Depression Recurrent, and anxiety disorder.The facility provided an Interagency Certification of Screening results (OBRA) dated 4/16/15 for R54 which does not identify R54 as having a Serious Mental Illness diagnosis and shows the screening is good for 90 days. There was no PASRR for R54 in his Electronic Medical Record.On 2/23/2026 at 12:40 PM, V15 (Social Services Director) and V14 (Admissions and marketing) said the admission department looks for PASRRs when a resident is admitted . 02/23/2026 1:24 PM, V1 (Administrator) said the PASRR for R54 was ordered by the facility today. The facility provided PASRR screening…
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 before2026-02-25 · 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 safely transfer a resident and failed to ensure fall interventions were in place for 2 of 21 residents (R73, R32) reviewed for safety in the sample of 21.The findings include:1.R73 has diagnoses that include traumatic subdural hemorrhage, dementia and unsteadiness of feet. On 2/22/26 at 10:12 AM, R73 was in bed alert and pleasant. V17 (Certified Nursing Assistant-CNA) was also in the room assisting R73 up from bed to wheelchair. V17 (CNA) placed R73's wheelchair at the side of the bed. Then assisted R73 to sit at the edge of the bed. V17 placed R73's walker in front of him and instructed R73 to get up. R73 placed both of his hands in the walker, leaned forward and used the walker to pull himself up, but he was not able to. R73 stated ok, I'll try one more time. Again, R73 leaned forward and use the walker to pull himself up. V17 put his hands under R73's armpits and lifted R73 in standing position. V17 then instructed R73 to use his walker to turn and sit in his wheelchair. V17 went behind R73's wheelchair,…
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 · D2026-02-25 · 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 ensure nutritional supplements were given for a resident with significant weight loss. This applies to 1 of 8 residents (R11) reviewed for weight loss in the sample of 21. The findings include: 1. R11's face sheet shows she has diagnoses including major depressive disorder, unspecified dementia, severe psychotic disturbance, weakness, cognitive communication deficit, and post-traumatic stress disorder. On 2/22/26 at 10:10 AM, R11 was sitting in the dining room with her breakfast tray in front of her. She was served eggs, oatmeal and milk and her nutritional supplement was not provided. At 11:57 PM, R11 was in the dining room sitting at the same table. At 12:41 PM, lunch trays were delivered to the 2nd floor, R11 was served her noon meal, and her nutritional supplement shake was not provided. On 2/23/26 at 12:51 PM, R11 was sitting in the dining room during the noon meal. She was served a regular tray feeding herself. R11 was not given her nutritional shake during the noon meal. On 2/23/26 at 12:17 PM, 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 · D2026-02-25 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
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 administer medications as ordered at ordered times. There were 26 opportunities with 2 errors resulting in a 7.6% error rate. This applies to 1 of 4 residents (R6) observed in the medication pass.On 2/22/26 at 11:00 AM, V13 (Licensed Practical Nurse-LPN) prepared R6's morning medications including Amiodarone 200 mg (milligrams) give via g-tube two times a day for arrhythmia and Metoprolol 25 mg give half of tablet two times a day for hypertension. R6 crushed the medications separately and administered the medications through R6's g-tube. At 11:30 AM, V6 said R6 was her last resident for morning medication pass. On 2/26/26 at 10:51 AM, V16 (LPN) said morning medication pass should be from 8:00 AM to 10:00 AM. R6's Medication Administration Record dated February 2026 shows orders to administer at 9:00 AM; amiodarone 200 mg one tablet via g-tube two times a day and metoprolol 25 mg give half of tablet two times a day. The facility's Medication Administration Policy dated 3/24 states, To ensure that 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.
Show the remaining 23 citations
- Potential for harm · Dcited before2025-12-31 · 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 an antibiotic was given as ordered for 1 of 3 residents (R2) reviewed for medications in the sample of 6. The findings include: R2's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include pneumonia, major depressive disorder, osteoporosis, weakness, unsteadiness on feet, severe protein calorie malnutrition, hypothyroidism, pain in right shoulder, chronic obstructive pulmonary disease, hypotension, legal blindness, dysphagia, generalized anxiety disorder, decreased white blood cell count, and bipolar disorder. R2's Hospital Discharge instructions dated 12/18/25 showed an order for doxycycline 100 mg (milligrams) to be given daily for 3 days starting 12/19/25.R2's December 2025 eMAR (electronic Medication Administration Record) showed and order for doxycycline monohydrate. give 1 capsule by mouth one time only for 3 days. R2's same December eMAR showed R2's doxycycline was administered only once on 12/19/25. R2's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-06-23 · 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 the dishwasher was sanitizing dishes and failed to ensure kitchen staff washed hands to prevent cross contamination to clean dishes which applies to all 77 resident in the facility reviewed for kitchen sanitation. The findings include: The Facility Data Sheet dated 6/17/25 showed the facility had census of 77 residents. On 6/17/25 at 9:20 AM, V4 Dietary Aide was using the dishwasher in the kitchen. V4 was not wearing gloves. V4 unloaded a clean rack of dishes, loaded a dirty rack of dishes, and the moved the clean dishes and rack without washing their hands. At this time the sanitizer 5 gallon bucket under the dirty tray line was empty. On 6/17/25 at 10:00 AM, V3 Dietary Manager retrieved test strips from their office and checked the dishwasher. The test strip stayed white showing no sanitizing agent in the dishwasher. V3 noted the 5 gallon sanitizer bucket was empty. V3 stated acceptable levels for chlorine is 50-100 parts per million (PPM) and Quaternary Ammonium (QUAT) sanitizer levels should 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 · Fcited before2025-01-10 · 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 store, prepare, and distribute food in a manner that would prevent foodborne illnesses. This applies to 71 residents who ate food from the kitchen. The findings include: On January 10, 2025 at 2:35 PM, V2 (DON/Director of Nursing) said two residents were NPO (Nothing By Mouth) and did not receive trays from the kitchen. On January 7, 2025 at 10:28 AM, during the initial tour of the kitchen, the dry food storage area was observed to have the following: -5 cartons of [Brand] tomato Juice from concentrate with a best if used by date of September 11, 2024. -16 packets of [Brand] creamy classic mashed potatoes with no 'received on' dates or expiration dates. -5 packets of tortillas with no 'received on' dates. -An opened 25-lb box of instant food thickener, left open to air, with no 'opened on' date. -An opened box of long grain rice with a bag within it, open to air, with no 'opened on' date. On January 7, 2025 at 10:50 AM, the milk refrigerator was checked, and did not contain a thermometer within 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 · E2025-01-10 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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 and interview, the facility failed to maintain a homelike environment. This applies to 8 of 8 residents (R7, R11, R17, R24, R43, R47, R50, R58) reviewed for environment in a sample size of 19. The findings include: On 1/7/25, during initial tour the following observations were made: 1. At 11:04 AM, surveyor went to R11 and R17's room. Both of them were not in their room. Next to R11's bed, there was hole in the wall and paint was peeling from various parts of the wall. On 1/8/25 at 10:23 AM, R17 stated, I want that hole fixed and wall repainted. On 1/8/25 at 10:25 AM, R11 stated, I don't like that hole and I want it fixed. R11's MDS (Minimum Data Set) dated 12/5/24, shows a BIMS (Brief Interview for Mental Status) score of 11, which means she is moderately impaired in cognition. 2. At 11:07 AM, inside R47's room, there was paint peeling from various parts of the room. Some parts of the floor were also missing base boards. R47 stated, It doesn't look nice like that, but it's no [NAME]. R47'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 · Ecited before2025-01-10 · 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
Based on observation, interview, and record review, the facility failed to dispose of controlled medication and verify the accuracy of controlled medication logs for residents with controlled medications. This applies to 4 out of 4 (R57, R5, R26, and R44) residents reviewed for controlled medications in a sample of 19. Findings include: 1. On 1/08/2025 at 9:30 AM, V4 (Licensed Practical Nurse/LPN) was asked to verify the controlled medications located in the 2-East medication cart. V4 said nurses confirmed they completed the end-of-shift handoff count of controlled medications by signing the accountability record log. V4 reviewed the log and confirmed the log for the AM shift on 1/08/2025 was not signed by the incoming morning nurse. V4 said R26 had an open medication bottle of Clonazepam 0.5 mg (milligrams) with 42 tablets. V4 then said R26 did not have an Individual Controlled Drug Administration Record log to verify the medication's quantity. V4 said that nurses should ensure that all controlled medications have Individualized Controlled Drug Administration Record logs to verify…
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 before2025-01-10 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to label and store medications for residents receiving insulins and eye drops. This applies to 5 out of 5 (R61, R23, R44, R71, and R42) residents reviewed for medication storage in a sample of 19. Findings include: 1. On 1/08/2025 at 9:30 AM, the medication storage task was done with V4 (Licensed Practical Nurse/LPN) on the 2-East and 1-East medication carts. V4 remained present during the following observations: R44's Levemir insulin vial was opened and undated. R44's Levemir medication package bag said it was dispensed on 12/22/2024 and was also undated. R44's Order Summary Report dated 1/08/2025 showed an active order for Levemir Solution 100 UNIT/ML (Insulin Detemir) Inject 26 units subcutaneously in the morning for DM (Diabetes Mellitus). 2. R42's Humulin R insulin vial was open and dated with an open date of 11/11/2024. R42's Humulin R medication package had instructions to MUST DISCARD W/ IN 31 DAYS after opening. R42's Order Summary Report dated 1/08/2025 showed an active order for HumuLIN R Solution 100…
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 · D2025-01-10 · 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 assist residents needing assistance with eating, oral care, and grooming. This applies to 4 out of 4 residents (R57, R1, R28, and R26) reviewed for activities of daily living in a sample of 19. Findings include: 1. R57's EMR (Electronic Medical Record) showed she had multiple diagnoses including Alzheimer's disease, left-hand contracture, dysphagia, cognitive communication deficit, stage 4 pressure injury to the sacrum, seizures, and anemia. R57's MDS (Minimum Data Set) dated 12/04/2024 said she required substantial to maximal assistance with eating and was dependent on staff for her personal and oral hygiene needs. On 1/07/2025 at 11:30 AM, R57 was sitting in her reclining wheelchair in the dining room. R57 was confused and non-interviewable. R57 had overgrown facial hair on her upper lip and chin areas. R57's teeth were unkept they had food residue and had a foul mouth odor. At 12:30 PM R57 was trying to feed herself a folded slice of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-10 · 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 properly provide urinary catheter care for 2 of 2 residents (R44, R67) reviewed for urinary catheter care in a sample of 19. The findings include: 1. On January 8, 2025 at 10:14 AM, V18 (CNA/Certified Nurse Assistant) said he changed R44's catheter bag from the hanging bag to the leg bag. V18 said he washed the catheter bag by taking two capfuls of vinegar and water and pouring it into a piston with a syringe in it. V18 said he then pushed the vinegar and water mix into the tubing and the catheter bag and swished it around in the bag and then emptied it into the toilet. V18 said he then does this process again before following it up with water. V18 said he then puts the catheter bag into a plastic bag to dry. V18 said he would put the leg bag on during the day and the hanging catheter bag at bedtime. V18 showed the surveyor the catheter bag, which said the catheter bag was sterile and said not to re-sterilize. On January 9, 2025 at 9:54…
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 · D2025-01-10 · 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
Based on observation, interview, and record review, the facility failed to provide thickened liquids for a resident (R60) with an order for nectar-thickened liquids. This applies to 1 of 4 residents (R60) reviewed for diets in a sample of 19. Findings include: R60's EMR (Electronic Medical Record) showed he had multiple diagnoses including dementia, muscle weakness, and respiratory infection. R60's MDS (Minimum Data Set) dated 10/29/2024 said he required setup assistance for his meals and had an altered diet requiring thickened liquids. On 1/07/2025 at 12:25 PM, V9 (Certified Nurse Assistant/CNA) served R60 lunch in the dining room. R60's meal tray had multiple drinks including a cup of coffee and a carton of milk, both were thin liquid consistency. R60's meal ticket said he required nectar thickened liquids. V8 (CNA) was asked to assess R60's served drinks and said he was served the incorrect type of liquids. V8 removed the drinks and proceeded to thicken R60's coffee and milk. V8 said the dietary staff prepares the residents' meal trays in the kitchen, including their drinks. V8…
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 before2025-01-10 · 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 PPE (Personal Protective Equipment) for residents who were on EBP (Enhanced Barrier Precautions). This applies to 2 of 2 residents (R64, R44) reviewed for infection control in a sample of 19. The findings include: 1. On January 8, 2025 at 12:03 PM, V14 (Restorative Aide/CNA-Certified Nurse Assistant) was in R64's room and was not wearing a gown. R64's doorway showed he was on EBP, with gowns and gloves in an isolation cart outside the room. V14 provided incontinence care, assisted in changing his clothes, and assisted in transferring the resident from the bed to the wheelchair. On January 9, 2025 at 10:10 AM, V14 said if a resident was on EBP, the staff should wear gloves and a gown. On January 9, 2025 at 10 AM, V16 (RN/Registered Nurse) said the staff should wear a gown and gloves when giving direct patient care for residents on EBP. V16 said residents with catheter bags and G-Tubes (Gastrostomy) would require gowns and gloves. V16 also said transferring and incontinence care would be considered direct…
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 before2024-12-11 · 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 ongoing assessments of a resident after the resident had sustained a fall with injury for 1 of 3 residents (R2) reviewed for quality of care in the sample of 3. The findings include: R2's current care plan showed R2 was at high risk for falls due to her history of repeated falls and her impaired cognition related to her diagnosis of dementia. R2 was dependent on staff for cares. R2's fall investigation report dated 11/29/24 showed R2 sustained an unwitnessed fall out of bed on 11/28/24 around 4:00 AM. R2 was immediately assessed by staff and found to have no complaints of pain or obvious injuries. The report showed R2 began complaining of left leg pain on 11/29/24. An X-ray of R2's left leg was completed in the facility on 11/29/24. R2's X-ray report dated 11/29/24 showed R2 had a proximal left femur fracture. The facility attempted to send R2 to the hospital for an evaluation but V18 (R2's family/power of attorney/POA) did not want R2 hospitalized . R2 remained in facility with orders for pain management and 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 · Dcited before2024-12-11 · 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
Based on observation, interview and record review the facility failed to ensure a resident, that had sustained a recent fall with injury, had fall interventions in place for 1 of 3 residents (R2) reviewed for safety and supervision in the sample of 3. The findings include: R2's fall investigation report dated 11/29/24 showed R2 sustained an unwitnessed fall out of bed on 11/28/24 that resulted in R2 fracturing her left femur. R2's care plan revised 11/29/24 showed R2 was at high risk for falls due to her history of repeated falls and her impaired cognition related to her diagnosis of dementia. R2 was dependent on staff for cares. The plan showed R2 had previously fallen out of bed on 8/22/24, where she sustained an unwitnessed fall out of bed, resulting in a fracture to her right femur. The plan showed, Keep bed in lowest position . Provide floor mats on sides of resident's bed . On 12/11/24 at 9:39 AM, R2 was in bed, awake, but babbling incoherently. No mats were noted on the floor next to either side of R2's bed. On 12/11/24 at 12:02 PM, R2 remained in bed, digging through her…
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 · D2024-12-11 · tag F0777 — isolatedProvide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
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 x-rays were obtained in a timely manner for a resident with an acute injury. This applies to 1 of 3 residents (R1) reviewed for radiology in the sample of 3. The findings include: On December 11, 2024, R1 was sitting up in a reclining wheelchair coloring in the dining room. She had a long- leg cast to her right lower leg. The facility's injury of unknown cause report dated November 28, 2024 shows, Resident complained of pain on 11/27 (day prior) at 6AM during care. CNA (Certified Nursing Assistant) on duty alerted NOD (nurse on duty) and pain medication was given. NOD completed body assessment on resident, no findings. At 7:15 AM morning CNA was about to give resident a shower, but resident complained of pain again, and CNA alerted NOD that resident was complaining of pain, and she did not want to move resident. NOD alerted DON (Director of Nursing) and DON went into resident's room to assess resident. DVT (deep vein thrombosis) was suspected. DON phones NP (Nurse Practitioner) who gave orders for venous…
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 · D2024-07-30 · tag F0563 — failed to protect the right to visitors — isolatedHonor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
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 policy by not ensuring restricted visitor information was posted for 2 of 3 residents (R1, R3) reviewed for safety in the sample of 3. The findings include: 1. R1's face sheet printed on 7/30/24 showed diagnoses including but not limited to dementia with mood disturbance, psychosis, dysphagia, and adult failure to thrive. The same face sheet showed the names of five family members allowed to visit R1. The face sheet showed instructions to call R1's state guardian if anyone else attempts to visit. R1's facility assessment dated [DATE] showed severe cognitive impairment and total staff assistance required for all ADLs (activities of daily living). R1's July 2024 physician order summary showed hospice care and receiving comfort medications. On 7/30/24 at 10:00 AM, V3 (Social Service Director/SSD) stated R1 was admitted to the facility in November of 2022 and at that time, only five family members were allowed in to see her (R1).…
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 before2024-02-28 · 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 — the official record, unedited, may be distressing
Based on interview and record review the facility failed to test and record the concentration level of the sanitizer in the low temperature dishwasher at breakfast, lunch, and supper. This failure has the potential to affect all 79 residents residing in the facility. The findings include: During the initial tour of the kitchen on 2/26/24, V11, Dietary Manager, said the sanitization level of the dishwasher should be checked three times a day before each meal. The instructions on the Dish Machine Log-Low Temp provided by the facility for the month of February (2024) shows the sanitizer concentration should be recorded three times a day; breakfast, lunch, and supper. The same log does not have a sanitization concentration level recorded at lunch or supper on 2/25/24 or breakfast on 2/26/24. The CMS 671 form dated 2/26/24 shows there are currently 79 residents residing in the facility.
- Potential for harm · E2024-02-28 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to follow recipes to ensure nutritional value and palatability was retained for 9 residents of 9 residents (R21, R8, R7, R1, R19, R383, R38, R75, and R45) reviewed for pureed diets in the sample of 18. The findings include: On 2/26/24 at 11:16 AM, V11, Dietary Manager/Cook used water to thin the broccoli casserole for the pureed chicken broccoli casserole. On 2/26/24 at 12:30 PM, surveyors obtained a sample tray for the pureed lunch meal, sampled the pureed chicken broccoli casserole, and found it to be bland, lacking flavor, and watery tasting. On 2/27/24 at 2:02 PM, V11 said it is important to follow the recipe to maintain nutritional values. V11 said water or milk can be used to thin pureed foods, the recipe does not show which to use. The facility's F/W 23/24 Menu for Week 3 shows the lunch meal for Monday includes Chicken Broccoli Casserole. The facility's Pureed Chicken Broccoli Casserole recipe provided by the facility for F/W 23/24-Week 3 Monday Lunch shows, May add hot broth and/or thickener, as needed,…
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 before2024-02-28 · 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 observation, interview and record review the facility failed to ensure a resident with sutures to a surgical wound was assessed and removed in a timely manner. The facility also failed to ensure sutures were removed from a resident's forehead laceration. This applies to 2 of 18 residents (R37 & R38) reviewed for necessary care and services in the sample in 18. The findings include: 1. On February 26, 2024, at 12:02 PM, R38 was sitting up in the dining room. She had a surgical boot on her left foot. Her left foot was wrapped with a gauze dressing. On February 27, 2024, at 10:27 AM, R38 was sitting up in the dining room. She was wearing a surgical boot on her left foot. Her left foot was wrapped with a gauze dressing. On February 27, 2024, at 2:01 PM, R38 was lying in bed. V3 Registered Nurse (RN) was changing R38's dressing to her left foot. R38's left foot was very dry and had a tint of yellow. Her 2nd toe was missing. There were sutures in place of the toe. V3 RN stated, she has had the sutures since she came back from the hospital. She wasn't sure why R38 still had…
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 before2024-02-28 · 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 pressure injuries prior to an unstageable necrotic wound and failed to assess a pressure injury when identified. The facility also failed to ensure pressure reliving interventions and treatments were in place. This applies to 2 of 7 residents (R72 & R62) reviewed for pressure injuries in the sample of 18. The findings include: 1. R72's face sheet shows she is a [AGE] year-old woman with diagnoses to include: diabetes mellitus type two, dementia, pressure ulcer of left heel, stage 4, non-pressure chronic ulcer of left ankle with fat layer exposed, and adult failure to thrive. On February 26, 2024, at 9:58 AM, R72 was asleep in bed. The head of the bed was elevated to an approximate 45-degree angle. She was turned on her left hip. At 11:17 AM, 12:17 PM and 1:50 PM, R72 was lying in the same position she was in at 9:58 AM. On February 27, 2024, at 12:31 PM, V3 Registered Nurse (RN) was changing R72's wound on her left heel. R72's left…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-28 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure all residents were offered and/or received the recommended pneumococcal immunizations to 1 of 5 residents (R72) reviewed for immunizations in the sample of 18. The findings include: R72's admission Record dated 2/28/24 shows R72 is a [AGE] year-old female admitted to the facility on [DATE]. R72's diagnoses include, but are not limited to, diabetes mellitus, type 2, dementia, adult failure to thrive, hypertensive heart disease, and anemia. R72's Immunization Report dated 2/27/24 does not show any documentation of R72 having received or been offered a Pneumococcal vaccine. On 2/29/24 at 9:15 AM, V5, Infection Prevention Nurse, said they offer residents a pneumococcal vaccine on admission. The facility was unable to provide documentation showing R72 was offered, received, and/or refused a pneumococcal vaccine. Per current Centers for Disease (CDC) guidelines, R72 was eligible and recommended for a Pneumococcal Vaccine (PCV15 or PCV20). 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 before2024-01-31 · 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 protect a residents right to be free from resident to resident sexual abuse. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 6. The findings include: R1's face sheet shows she was admitted to the facility on [DATE] with diagnoses including schizophrenia, personal history of other mental and behavioral disorders, and hypertensive heart disease. R1's care plan initiated on 2/4/22 shows she has a language communication barrier and can speak only simple English. The care plan also shows she has a cognitive deficit and prefers to be more independent with activities and chooses to observe from a distance. On 9/25/23 an update to her care plan was initiated identifying R1 is at risk for abuse due to having a mental illness and noncompliance with medications. R2's face sheet shows he was admitted to the facility on [DATE] with diagnoses including abnormality of gait and mobility, muscle weakness, and acquired absence of right leg below…
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 before2023-11-07 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents were free from physical abuse for 3 of 13 resident's (R2, R4, R8) reviewed for abuse in the sample of 13. The findings include: 1. The facility's Incident Report Form dated 11/2/23 shows R1 was seen in an altercation with R2. On 11/7/23 at 10:40 AM, R2 was sitting in his room. R2 had no visible marks on his face. R2 (when asked what happened with R1) said I'm alright, and motioned this surveyor to leave his room. On 11/7/23 at 11:55 AM, V2 Director of Nursing (DON) said R1 hit R2 in the face with a cup. V2 said V11 Certified Nursing Assistant witnessed and reported it to her. V2 said she reviewed the cameras and saw R2 walking in the hall with a cup in his hand. V2 said R1 snatched the cup out of R2's hand and then hit him in the face with it. V2 said R1 and R2 were separated and R1 was put on 1:1 observation and then sent out to the hospital for a psych evaluation. V2 said R2 sustained a small red mark on the left side of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-01 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to protect a resident's right to be free from physical abuse by another resident. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 3. The findings include: R1's admission Record indicated R1 was a [AGE] year-old male with a diagnosis of schizophrenia. A facility assessment that was done on 9/5/23 showed R1's cognitive skills were moderately impaired. R1's Care Plan showed R1 was at risk for abuse. R2's admission Record indicated R2 was a [AGE] year-old male with a diagnosis of dementia and schizophrenia. On 11/1/23 at 11:05 AM, R1 was asked if he felt safe in the building. R1 shrugged his shoulders indicating he did not know. R1 pointed to R2 and said he was punched by R2. R1 indicated he was punched in the right eye/cheek area. R1 said it hurt when he was punched. On 11/1/23 at 10:44 AM, V6 (Receptionist) said on 10/23/23 during dinner she witnessed the following: R2 took some food off R1's plate, R1 pulled his plate away from 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.
- No harm found · C2024-02-28 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, and record review the facility failed to post their nurse staffing information. This has the potential to affect all 79 residents residing in the facility. The findings include: On 2/28/24 at 10:55 AM, the nurse staffing information was not posted. On 2/28/24 at 10:58 AM, V10 Receptionist said she didn't have any staffing numbers posted, just the schedule of who is working. V10 said she directs staff to their assignment when they come in for the day. On 2/28/24 at 11:51 AM, V2 Director of Nursing (DON) said staffing information was not posted. V2 said the staffing information should be posted. V2 said it is normally posted near the entryway of the facility. The CMS 671 dated 2/26/2024 shows a resident census for 79.
“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
$135,606 in federal fines across 2 penalties. 1 Medicare payment denial on record.
- $26,720 — penalty dated 2026-04-13
- $108,886 — penalty dated 2023-09-26
- Medicare payment denial — starting 2026-03-20 for 10 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to ALIYA HEALTHCARE — 14 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 | 1 of 5 | 2.0 | -1.0 vs chain |
| Health inspection | 1 of 5 | 2.1 | -1.1 vs chain |
| Staffing | 2 of 5 | 1.4 | +0.6 vs chain |
| Quality measures | 2 of 5 | 3.8 | -1.8 vs chain |
The other 13 homes this chain runs (chain average 2.0★, 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 |
|---|---|---|---|---|
| LAUREATE CHICAGOLAND HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 99% | since 08/30/2019 |
| RPFG HOLDINGS INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 09/01/2019 |
| DEMPSEY, KATHLEEN | Individual | W-2 MANAGING EMPLOYEE | — | since 08/30/2019 |
| AHMAD, SHAUN | Individual | CORPORATE OFFICER | — | since 08/30/2019 |
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $446K 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 146159. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-25, 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.