West Chicago Living and Rehab Center
928 Joliet Road, West Chicago, IL 60185 · For profit - Corporation · 120 certified beds · (630) 231-9292 Medicaid only — no Medicare
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Mar 2026
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0567)
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (46) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $143,375 in federal fines (most recent 2024-11-12)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- it did not file the payroll staffing data CMS requires — its 1 of 5 staffing rating is the rating CMS assigns for not reporting, not a measure of how many nurses are on the floor
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 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 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 | 29.8% | 13.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.3% | 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 | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 99.3% | 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 | 0.9% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 2.4% | 14.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 27.6% | 18.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.0% | 4.8% | 4.7% | check this* — see note marked star below the table |
| Long-stay residents with worsening bladder/bowel control | 4.8% | 20.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 65.1% | 21.7% | 17.1% | check this† — see note marked dagger below the table |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 63.1% | 79.4% | better |
| Long-stay hospitalizations per 1,000 resident days | 3.01 | 2.02 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.40 | 2.22 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
† This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.
‡ 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.
Therapy staffing: this home’s payroll records show <0.01 therapist hours per resident per day in 2026Q1 — more than 0% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 29% 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 — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| 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 — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
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
No payroll-based (PBJ) staffing hours are on file for this home — and the record suggests that is because it did not report them. CMS rates its staffing 1 of 5, which is the rating CMS assigns when a home does not report. Every Medicare-certified nursing home is required to submit its actual payroll data quarterly, and that submission is what makes staffing numbers auditable rather than a claim. A home that does not file is not the same as a home with no data yet: ask this home directly what its nurse-to-resident ratios and weekend RN coverage are, why its payroll data is not filed, and weigh the independent health-inspection score heavily in the meantime.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
46 citations, most serious first. The 13 most serious are shown; the remaining 33 are one tap away and print in full.
- Immediate jeopardy · Kcited before2024-11-12 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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 have a system or any policies in place to identify services needed to meet the intimacy rights of mentally ill female residents of child-bearing age. This failure resulted in one female resident (R1) becoming pregnant by another resident and experiencing psycho-social harm when she was hospitalized and per the hospital Psychiatrist, is now in a catastrophic situation. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 6/21/2024 when R1 told staff that she had an interest in R2 (a male peer) and refused condoms and other forms of birth control. This applies to 1 of 10 residents (R1) reviewed for intimacy rights and has the potential to affect 6 other female residents (R12-R17) of child-bearing age living in the facility. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 11/07/2024 at 8:58 AM and the IJ template was provided. V1 provided an Immediacy Removal Plan at 3:15 PM 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.
- Immediate jeopardy · Jcited 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 resident's (R1) right to be free from sexual abuse from another resident (R2) with known history of sexual behaviors. This failure resulted in R1 being sexually abused by R2. This applies to 1 of 6 residents (R1) reviewed for sexual abuse in the sample of 6. This resulted in Immediate Jeopardy. The Immediate Jeopardy began on January 5, 2024, when the incident between R1 and R2 occured. The facility failed to use increased interventions of supervision when they identified R2 as hypersexual to ensure R1's safety. This failure resulted in R1 being sexually abused. V1 (Administrator), V2 (Director of Nursing), V3 (Assistant Director of Nursing) and V13 (Human Resource) were notified of the Immediate Jeopardy on January 23, 2024, at 4:27 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on January 24, 2024, but non-compliance remains at Level Two because additional time is needed to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-01-31 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to review and revise a resident's (R2) plan of care, after the resident exhibited hypersexual behaviors. This failure resulted in R2 sexually abusing R1 on January 5, 2024, resulting in R2's arrest by the local police and charged with two counts of domestic battery. This applies to 1 of 4 residents (R2) reviewed for behavioral care plans in the sample of 6. The findings include: R2 was admitted to the facility on [DATE]. R2 had multiple diagnoses including schizophrenia, schizoaffective disorder, bipolar disorder, restlessness and agitation, violent behavior, psychosis not due to a substance or known physiological condition, based on the face sheet. R2's quarterly MDS (Minimum Data Set) dated December 5, 2023 showed that the resident was cognitively intact. The MDS showed that R2 required substantial/maximal assistance with oral, toileting and personal hygiene, bathing/shower, upper and lower body dressing, putting on/taking off footwear and 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.
- Potential for harm · Dcited before2026-06-04 · 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 provide pain medication to a resident in pain per physician orders. This applies to 1 of 3 residents (R4) reviewed for pain in a sample of 8.The findings include: R4's Hospital Physical Medicine Physician progress note, dated 5/11/26, shows R4's diagnoses included chronic low back pain, right sciatica, and myofascial pain. R4 was referred for a nerve test of her legs and a trigger point injection of her low back. MAR (Medication Administration Record), dated May 2026, shows R4 received a physician order for tramadol as needed for pain on 5/18/26 at 7:48 PM . The MAR shows tramadol was first administered 5/19/26 at 4:37 PM for back pain described by R4 as 9 on a scale of 10 with 10 being the worst pain.On 6/2/26 at 11:05 AM, R4 stated once her Tramadol was ordered by V5 (Nurse Practitioner) it .took forever for them to give it to me once it was ordered. R4 stated her pain was a 9 on a scale of 0 to 10 with 10 being the most pain she had experienced. R4…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-29 · 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 keep R1 free from abuse. This applies to 1 of 3 (R1) residents reviewed for abuse. The findings include:R1's final incident investigation report dated 3/11/26 shows On 3/6/26 at 9:40 PM, in the dining room area, (R1) was pushing a chair when (R2) was walking around the dining room and came up to him and pushed (R1) for no apparent reason, at which time (R1) fell to the ground. No verbal argument or words were exchanged prior to the incident. Both residents were immediately separated by staff that were in the dining room area and (R2) was placed one-to-one staff monitoring. (R1) was assessed by charge nurse and presents with no redness, bruising, complaints of pain or discomfort, and reports feeling safe in the facility. The medical doctor for both residents was notified, and police were called. Both residents' representatives were notified of incident. Investigated initiated. Physical abuse is founded. Conclusion: (R1) had moved (R2)'s phone from 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 · D2026-03-03 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure residents were able to exercise their rights to retain personal items and failed to provide justification as to why those personal items were confiscated.This applies to 2 of 3 residents (R4 and R5) reviewed for resident rights in the sample of 15.The findings include: Face sheet, dated 2/25/26, shows R4's diagnoses included major depressive disorder.MDS (Minimum Data Sheet), dated 1/1/26, shows R4's cognition was intact.On 2/24/26 at 2:40 PM, R4 stated in October of 2025 R5 was having pain in his stomach which caused him trouble bending forward. R4 stated he ordered an object grabber for R5 and attempted to provide the grabber to R5 however V3 (Psychiatric Rehabilitation Services Director) and V5 (Former Administrator) both stated they were concerned the grabber could be used as a weapon, confiscated the object, and told R4 that R5 required a physician order to utilize an object grabber. R4 stated he and R5 obtained a physician order for 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 before2026-03-03 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent the abuse of a facility resident.This applies to 1 of 4 residents (R7) reviewed for abuse in a sample of 15.The findings include: Facility Abuse Prevention Policy, dated 10/24/24, shows, The facility affirms the right of our residents to be free from abuse. The facility has attempted to establish a resident sensitive and resident secure environment. The policy shows, Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. Verbal abuse is the use of oral. language that willfully includes disparaging and derogatory terms to residents or families. regardless of an individuals' age, ability to comprehend, or disability. Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment 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 · D2026-03-03 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to report resident allegations of abuse.This applies to 1 of 4 residents (R1) reviewed for abuse in the sample of 15.The findings include:On 2/24/26 at 1:36 PM, V6 (Psychiatric Rehabilitation Services Counselor) stated R1 reported that R2 threatened to hit R1 with a walker and he immediately told V2 (Assistant Administrator). On 2/24/26 at 10:01 AM, V2 (Assistant Administrator) stated she spoke to R1 who told V2 that a resident was shaking her walker at her so V2 reported the allegation to V5 (Former Administrator) who initiated an investigation. V2 stated R1 told V2 that R1 was scared and the facility sent R2 out to the psychiatric hospital. Investigation Assessment (Resident to Resident Aggression), dated 1/26/26 and completed by V5 (Former Administrator), shows an investigation was conducted regarding resident aggression between R1 and R2. Investigation document, dated 1/27/26, shows on 1/26/26 an incident occurred between R1 and R2 and R2 was placed on 1:1 monitoring. The document shows R1 was sitting in the dining room…
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 before2025-06-27 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide cool and comfortable room environments. This applies to 5 of 5 residents (R1, R2, R3, R5 and R17) reviewed for comfortable room environments in a sample of 17. The findings include: 1. Face sheet, printed 6/27/25, shows R1 resided on the A hall of the facility. MDS (Minimum Data Set), dated 5/5/25, shows R1 was cognitively intact. On 6/23/25 at 11:45 AM, R1 stated at that moment her room temperature was acceptable but for the prior two weeks the temperature of their room was very hot, uncomfortable and unbearable. R1 stated her room was so hot she threatened to call IDPH (Illinois Department of Public Health) if the air conditioning was not repaired. R1 stated facility administration offered to move her to a different room but R1 stated she felt like all of the rooms were too hot in the facility because the air conditioner was not working correctly. At 1:50 PM, R1 stated the facility needed to fix their air conditioner that had not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-12 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to protect a resident's privacy. This applies to 1 of 4 residents (R4) reviewed for privacy in a sample of 4. The findings include: On June 10, 2025 at 10:04 AM, R4 said her privacy rights were broken by her social worker. R4 said V3 (PRSC/ Psychiatric Rehabilitation Services Coordinator) released information that should only be discussed between case managers. R4 said V3 released her information to R1. R4 said V3 told R1 about her housing situation and the program she was a part of. R4 said this occurred about a week ago and she reported it to the administrator. R4 said R1's information was not spread, but hers was. On June 10, 2025 at 12:42 PM, V3 said R1 had come to him asking for a direct discharge, and he explained to her it was not always possible for residents to be discharged in the timeframe R1 expected. V3 said he told R1 even if she did everything right and got all the paperwork together, like R4, they still may not be able to get the housing accomplished. On June 10, 2025 at 2:54 PM, V2 (DON/Director of 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.
- Potential for harm · F2025-05-22 · 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 the dishes are sanitized during dish washing procedure and failed to ensure that dented cans were separated from the in-use cans. This applies to all 88 residents that received foods prepared in the facility kitchen. The findings include: Facility's CMS Application Form for Medicare/Medicaid dated May 19, 2025, showed that the facility census was 88 residents. Facility provided information that there are no residents on NPO (nothing by mouth) status. On May 19, 2025, at 9:24 AM, the initial tour of the facility's kitchen was conducted in presence of V4 (Dietary Manager). The dry storage area had 3 cans (6 pounds, 6 ounce each) of Salsa Para Enchiladas that were dented at the seams. These cans were placed on shelving with other canned goods and had a handwritten delivery date of February 14, 2025, on them. V4 stated that the dietary staff must have missed the dents on top of the corners. At the dish machine, V5 (Dietary Aide) was seen washing the dishes at the dirty side of the machine and placing…
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 before2025-05-22 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their water management program for Legionella. This applies to all 88 residents residing in the facility. The findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid dated May 19, 2025, showed the facility's census was 88 residents. On May 20, 2025, at 3:39 PM, V7 (Maintenance Director) said for the facility's water management plan, he flushes the water in empty resident rooms. V7 said he uses an electronic maintenance work order system and documents his water management task in the electronic system. V7 continued to say when he documents the Daily Building Water Management Plan in the electronic system, it means he flushed the water in the empty resident rooms and the soiled utility room. V7 said the facility has an ice machine that he cleans every six months. V7 said he cleaned it when he started at the facility in December 2024 because it was obvious it had not been cleaned in a long time.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-05-22 · tag F0881 — failed to use antibiotics responsibly — widespreadImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to follow their policy for antibiotic stewardship and have a standardized tool to identify infections in residents. This applies to all 88 residents residing in the facility. The findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid dated May 19, 2025, showed the facility's census was 88 residents. On May 20, 2025, at 1:08 PM, V3 (Infection Preventionist Nurse) said when a resident is started on an antibiotic, V3 will log the information into the EMR (Electronic Medical Record) Infection Control Module. V3 said this information includes the date of symptom onset, the signs and symptoms, if isolation is required, diagnostic results, and which anti-infective was prescribed. V3 said she does not use McGeer's criteria to determine if a resident has an infection. V3 said facility nurses will conduct antibiotic monitoring for residents receiving antibiotics, which includes the type of infection, vital signs, and if symptoms are improving. V3 said the facility nurses do not use McGeer'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.
Show the remaining 33 citations
- Potential for harm · E2025-05-22 · tag F0806 — failed to honor food preferences — patternEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to provide a substitute meal option with similar nutritional content as the main entrée for the lunch meal. This applies to 6 of 6 residents (R2, R10, R23, R34, R52, and R68) reviewed for dining in the sample of 18. The findings include: On May 19, 2025, at 9:32 AM, V6 (Cook) stated that she prepared baked chicken for the main menu entrée and is going to prepare turkey sandwiches for the substitute menu. Facility Daily spreadsheet for spring summer menus for week 4 Monday included Baked chicken (1 portion=3 oz/ounce protein). On May 19, 2025, at 12:03 PM, at the lunch meal, residents who ordered the substitute meal received a turkey sandwich made with slices of deli turkey, chopped lettuce and tomato in between two slices of bread and R2, R10, R23, R34, R52, R68 were served the same. When asked, how many slices of deli turkey she used, V6 (Cook) stated that she added about 3 1/2 slices of turkey per sandwich. V6 showed a recipe for Deli Sandwich (serving size 4 oz/ounce =3 oz protein) she used to prepare 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 before2025-05-22 · 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 follow physician's order for ID (Infectious Disease) consultation. This applies to 1 of 1 resident (R59) reviewed for physician orders in the sample of 18. The findings include: R59 had multiple diagnoses including unspecified valve endocarditis, and infection and inflammatory reaction due to cardiac valve prosthesis, based on the face sheet. R59's quarterly MDS (minimum data set) dated March 22, 2025, showed that the resident was cognitively intact. On May 19, 2025, at 10:35 AM, R59 stated that she is on antibiotic therapy due to endocarditis. R59's order report showed an active verbal (over the phone) order since June 13, 2024, for, Doxycycline Hyclate oral tablet 100 mg, give 1 tablet by mouth one time a day for Endocarditis /heart valve. Give daily until seen by ID. R59's EMR (Electronic Medical Record) including physician orders and progress notes from June 13, 2024, through May 20, 2025, showed no evidence that the resident was seen by the ID to evaluate the need for continued use of the Doxycycline Hyclate…
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 · D2025-05-22 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
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 did not receive an unnecessary medication. This applies to 1 of 2 residents (R5) reviewed for antibiotic use in the sample of 18. The findings include: The EMR (Electronic Medical Record) showed R5 was admitted to the facility on [DATE], with multiple diagnoses including chronic kidney disease, hypertensive heart disease without health failure, and type 2 diabetes mellitus. On May 20, 2025, at 1:08 PM, V3 (Infection Preventionist Nurse) said R5 received antibiotics for a facility acquired UTI (Urinary Tract Infection) in March 2025. V3 said R5 complained of swelling in her hands, feet, and face and requested a diuretic medication. V3 said laboratory tests were done, and an antibiotic was ordered. V3 said R5's laboratory results for R5's urine culture showed R5 did not have an infection and should not have received antibiotics. A progress note dated March 18, 2025, at 3:15 PM, by V8 (LPN/Licensed Practical Nurse) showed Resident…
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 · D2025-05-22 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to provide ground baked chicken to residents on mechanical soft diet. This applies to 2 of 3 residents (R1 and R79) reviewed mechanical soft diets in the sample of 18. The findings include: On May 19, 2025, at 12:03 PM, during tray line service, V6 (Cook) stated that she prepared mechanical soft diet by manually chopping the baked chicken and then added gravy to the same. V6 showed a container of chopped chicken cut up in varying pieces steeped in gravy. R1 and R79 whose diet tickets showed mechanical soft diet, were served the chopped chicken in gravy. Daily menu spreadsheet for week 4 Monday showed to serve ground deboned chicken with gravy. Recipe for ground deboned chicken with gravy showed to debone chicken and grind meat to correct consistency. On May 22, 2025 at 11:44 AM, V11 (Dietitian) stated that the facility should follow the recipe guidance for mechanically altered diets. Facility policy titled Therapeutic Diets (effective May 2020) Guideline: Therapeutic diets are prescribed by 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 before2025-04-04 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record reviews, the facility failed to protect R2's right to be free of abuse from another resident. This applies to 1 of 4 residents (R2) reviewed for abuse. The findings include: R2's Face Sheet showed R2 had been residing at the facility since 8/31/2022 for mental health care with diagnoses including schizoaffective disorder, depressive type, personality disorder, schizophrenia, nicotine dependence, and prediabetes. R2's 3/10/2025 MDS (Minimum Data Set) showed R2's cognition is intact. The facility's Incident Report of 3/27/25 to IDPH (Illinois Department of Public Health) showed that on 3/27/25 at 8:30 am R1 and R2 were standing in a line and R1 threw her cup of coffee on R2 and hit and pushed R2. On 4/3/25 at 1:00 PM, V1 (Administrator) showed the State Surveyor the video of the 3/27/25 incident and the video showed R1 throwing her coffee on R2 and striking and pushing R2. R1's witness statement of 3/27/25 showed that R1 admitted to punching R2 and throwing her coffee on R2. The facility's 3/27/25 Incident Report to IDPH did not have a witness statement…
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 before2024-11-12 · 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 protect the resident's right to be free from physical abuse. This applies to 1 of 3 residents (R9) reviewed for resident-to-resident physical abuse. The findings include: On 10/29/2024 at 11:15 AM, R9 said last week she told R7 to stop being rude to other residents in the dining room. R9 said R7 became upset and started to yell at her. R9 said when she was standing in line for her medications, R7 walked by her and shoved her against a bookcase. R9 said she sustained an injury to her left arm. R9 showed the surveyor her left arm, R9 had a linear abrasion to her forearm which appeared to be healing. R9 said R7 then walked by her again and punched her cold cut in her left eye. R9 said the staff then separated R7 from her. R9 said V15 (Licensed Practical Nurse/LPN) placed ice on her left eye and thankfully she did not get a bruise. R9 said she was scared. R9 said R7 then continued to be aggressive towards the staff and she had to be taken 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 · D2024-11-12 · tag F0622 — isolatedNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to have physician documentation to show the specific resident needs the facility could not meet for residents who were involuntarily discharged , and the efforts the facility made to meet those needs for a resident. The facility also failed to re-evaluate if a resident was able to be readmitted at the time of discharge from the hospital. This applies to 2 of 5 residents (R1 and R7) reviewed for discharges. The findings include: 1. The EMR (Electronic Medical Record) shows R7 was admitted to the facility on [DATE], and was involuntarily discharged from the facility on October 22, 2024. R7 had multiple diagnoses including major depressive disorder, generalized anxiety, asthma, suicidal ideation, bipolar disorder, and psychotic disorder. R7's MDS (Minimum Data Set) dated September 13, 2024, shows R7 was cognitively intact and was independent with all ADLs (Activities of Daily Living). R7 was always continent of bowel and bladder. R7's MDS continues to show…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-12 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to inform and provide a resident with a notification of involuntary discharge. This applies to 1 of 5 residents (R1) reviewed for discharges. The findings include: R1's EMR (Electronic Medical Record) showed an admission date of 4/23/2020 with diagnoses of schizophrenia, epilepsy, anxiety, myopia, astigmatism, and hyperlipidemia. R1's MDS (Minimum Data Set) dated 9/25/2024, shows R1 had behaviors not directed towards others daily. R1's MDS dated [DATE] showed she was permanently discharged from the facility and not anticipated to return. On 10/29/2024 at 2:00 PM, V3 (PRSD/Psychiatric Rehab Social Director) said R1 was confirmed to be pregnant on 10/17/2024. V3 said on 10/18/2024 she was informed R1 left the facility upset AMA (Against Medical Advice). V3 said R1's family found R1 shortly after she left the facility. V3 said then V1 (Administrator) instructed her to complete R1's petition for involuntary transfer from the facility to the hospital 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 · D2024-11-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to supervise a pregnant schizophrenic resident (R1) with a history of and known risk for elopement. This applies to 1 of 4 residents (R1) reviewed for safety. The findings include: R1's Face Sheet showed R1 had been residing at the facility since 4/23/2020 for mental health care with diagnoses of schizophrenia, anxiety disorder, epilepsy, and asthma. R1's 9/25/2024 MDS (Minimum Data Set) showed R1 experienced behaviors, including delusions. R1's 10/17/2024 Planned Parenthood progress note showed R1's pregnancy was confirmed by ultrasound with a gestational age of six weeks and three days. On 10/25/2024 at 12:37 PM, V7 (Licensed Practical Nurse/LPN) said she was R1's nurse on 10/18/2024. V7 said she was instructed not to administer R1's antipsychotic medications because R1 was confirmed to be pregnant on 10/17/2024. V7 said she observed R1 calm in the dining room that morning then she heard the announcement for code green (resident elopement). V7 said she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-20 · tag F0567 — failed to protect residents' money held by the home — isolatedHonor the resident's right to manage his or her financial affairs.
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 relinquish representative payee status back to a resident who requested to begin managing her own funds. This applies to 1 of 3 residents (R1) reviewed for resident rights in a sample of 3. The findings include: Face sheet, dated 8/19/24, shows R1 was admitted to the facility on [DATE] and R1's diagnoses included schizoaffective disorder bipolar type and unspecified psychosis. MDS (Minimum Data Set), dated 7/19/24, shows R1 was assessed as cognitively intact. On 8/19/24 at 12:48 PM, R1 stated she was waiting for the facility to provide a letter to Social Security stating that R1 was able to manage her own finances. R1 stated when she was admitted to the facility, she signed a document to allow her Social Security payments to be paid to the facility directly. R1 stated she wished to begin looking for an apartment and wished to have her payments come to her so that she could seek an apartment and be discharged from the facility. R1 stated the Social…
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 before2024-07-12 · 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 observations, interviews and record reviews the facility failed to use appropriate infection control practices for 3 COVID-19 positive residents (R15, R54, and R60), failed to have a system in place to monitor the measures in place to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water systems, and failed to store soiled linen properly. These failures have the potential to affect all residents at the facility. At the time of this survey, the facility's CMS 671 form (Long-Term Care Facility Application for Medicare and Medicaid) showed a census of 85 residents. 1. On 07/09/24 at 11:44 AM outside of R15's room there was a Stop Droplet plus precautions sign on R15's door and there were PPE (personal protective equipment) in the drawers outside her door. There was no eye protection inside the drawers as the sign showed needing. Outside of the room was an open carboard box with disposed PPE inside, yellow gowns and masks. On 07/9/24 at 01:17 PM V9 (Housekeeping and Laundry Director) was observed going into R15's room and she did…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-07-12 · tag F0887 — widespreadEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations interviews and record reviews the facility failed to provide education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine. This has the potential to affect all residents at the facility. At the time of this survey, the facility's CMS 671 form (Long-Term Care Facility Application for Medicare and Medicaid) showed a census of 85 residents. Findings include: On 07/11/24 at 03:50 PM, V7 (Activities Aide) said that she was offered the COVID-19 vaccination about 2 months ago but was not provided any education. On 07/11/24 at 04:16 PM, V8 PRSA (Psych Rehab Social Assistant) said that the facility did offer the COVID-19 vaccine about 2 months ago, but they did not offer any education on it. On 07/10/24 at 10:40 AM, V10 (Assistant Director of Nursing/Infection control Nurse) said that he did not offer any education about the COVID-19 vaccine and the benefits and risks, and potential effects associated with COVID-19. V10 said that he did not have any documentation showing that he offered staff any information or education…
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 before2024-07-12 · 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
Based on observations, interviews and record reviews the facility failed to provide a safe comfortable and homelike environment for 3 residents (R8, R31, and R76) in a sample of 21. Findings include: 1. On 07/09/24 at 11:32 AM R31 and R76's shared room was very warm and had 2 fans in the room. R31 said that in the afternoon the sun shines in the room and the room gets hotter. R76 said that air conditioning is not working on their side of the wing and that they must have fans in their room because it happens every day. R76 said that in the afternoon the room gets really bad and muggy. 2. On 07/09/24 at 02:50 PM, R8 said that it has been warm in her room for the last month or so. On 07/09/24 01:05 PM V9 (Housekeeping Director) was observed taking room temperatures. R8, R31 and R76's bedroom temperatures were 82 F. On 07/09/24 01:59 PM V9 said that the room temperatures should be between 70 - 81 degrees, and that the facility does not have a maintenance director and has not had one since the spring. V9 says that she reports the temperatures in the morning meeting and if 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 · Ecited before2024-07-12 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to invite residents to their quarterly care plan meetings and have an active care plan for a medical diagnosis. This applies to 6 of 6 residents (R8, R25, R64, R65, R76, and R83) reviewed for care plans in the sample of 21. The findings include: 1. On 07/09/24 at 11:48 AM R25 said he had not had a care plan meeting in a long time. R25 said he had not attended any this year. R25 said he would like to have a care plan meeting. R25 said they used to have regular care plan meetings, but not anymore. On 07/11/24 at 1:50 PM R25 said he was not invited and did not attend any of the care plan meetings that were scheduled in January and April of this year. R25 said attending the meetings makes him feel like he is contributing to his care. On 07/11/24 at 2:00 PM V8 (Psych Rehabilitation Services Assistant) said I am responsible for inviting the residents to the care plan meetings. There is no documentation showing that R25 was invited to the care plan…
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 before2024-07-12 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to waste compromised medications and label a medication with the opened on and use by date. This applies to medications for 4 residents (R6, R29, R36 and R74) in the facility of 85 residents. Findings include: 1. On [DATE] at 2:34 PM medication cart A was reviewed with V14 RN (Registered Nurse). Basaglar insulin Kwik Pen dispensed for R6 on [DATE] did not have an open on date or use by date written on the label that read expires 28 days after opening. V14 RN stated he did not know when it expired because there is no open or use by date filled out on the label. V14 stated using the insulin after the 28 days could have adverse effects. V14 RN stated using expired insulin could cause the resident to go into shock. 2. V14 identified a green pill in a medicine cup as haloperidol. V14 RN stated it was for R74 who was attending an outside skills program. V14 stated she left before 1pm and he didn't I didn't know R74 was gone when he pulled the pill.…
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 · D2024-07-12 · 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 enter a physician's order that reflects the resident chosen code status of DNR (Do Not Resuscitate). This applies to 1 of 10 residents (R10) reviewed for advanced directives in a sample size of 21. Findings include: R10 admitted to the facility on [DATE]. R10 has diagnoses that includes schizophrenia, asthma, bipolar disorder, major depressive disorder, osteoarthritis, fibromyalgia, and osteoporosis. R10's EMR (Electronic Medical Record) was reviewed. R10 did not have a physician's order for code status. Review of the facility binder contained R10's paper copy of her POLST (Physicians Order for Life Sustaining Treatment). On [DATE] at 4:29 PM, V1 (Administrator), stated she did not see a physician order for R10's code status in the EMR. V1 stated the nurse is responsible for obtaining and entering the physician code status. Psych-social is responsible for scanning the resident's POLST into the EMR if one is available and the DON (Director of Nursing) is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-12 · 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 make an appointment for a resident experiencing urinary urgency symptoms. This applies to 1 of 1 resident (R83) reviewed for quality of care in a sample of 21. The findings include: On July 9, 2024, at 2:11 PM, R83 said he had an enlarged prostate and had been waiting for three months to get an appointment to see someone. On July 11, 2024, at 12:53 PM, V4 (Medical Records/Scheduler) said depending on the availability of the doctor and insurance, appointments were usually made within the month. V4 said she had sent a referral for R83 on April 1, 2024, and an appointment was made on April 9, 2024, for June 20, 2024. V4 said she received a call from the doctor on May 23, 2024, saying they did not accept his insurance. V4 said she called another urologist's office on May 23, 2024, requesting for R83 to be seen there and did not have any documentation to show an appointment was made for R83. V4 said the insurance had already approved for him to see 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 · D2024-07-12 · tag F0687 — failed to care for feet properly — isolatedProvide appropriate foot care.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview the facility failed to provide foot care for one resident R51 in a sample of 21 residents. Finding include: On 7/09/24 at 12:51 PM, A staff member was observed telling R51 she could not go out to smoke without shoes. R51 removed their sock to show the staff her right foot. R51's toenails were very long and jagged. There was a black spot on R51's right toe. On 7/09/24 at 3:28 PM, R51 removed her socks to show surveyor her long claw like toenails on both of her feet. The bottoms of R51's feet were filthy and black. R51 stated she is wearing socks because she has a bunion and sore on her foot. R51 stated the foot doctor told her he was too busy to see her. On 7/11/24 at 3:49 PM, V17 CNA (Certified Nursing Assistant) stated she is not allowed to cut the toenails of residents they are seen by a foot doctor. On 7/11/24 at 6:33 PM, V4 Scheduler, stated she did not have documentation of when the podiatrist saw R51. The facility did not provide a policy on Activities of Daily living or foot care.
- Potential for harm · D2024-07-12 · tag F0711 — isolatedEnsure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
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 provide physician visits to 1 resident (R6) in a sample of 21 residents. Findings include: R6 admitted to the facility on [DATE] and has diagnoses that includes major depressive disorder, cataracts, arthritis, diabetes, chronic kidney disease, history of malignant neoplasm, hyperthyroidism, hypertensive heart disease, anxiety, anemia, and hyperlipidemia. R6's MDS (Minimum Data Set) dated 4/23/24 shows she is cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15. On 7/09/24 at 11:31 AM, R6 stated she has not seen her primary care physician V20 in over four months and has only seen him that one time. R6 stated she has only been seen by the nurse practitioner and medical students. R6 stated she should be seen by her primary care physician. On 7/11/24 at 4:29 PM, V1 Administrator stated V20 Physician does not come to the facility to round on the residents he sends his Nurse Practitioner. V1 Administrator stated V20 Physician should…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-12 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide Alcoholics Anonymous meetings for a resident with alcohol dependence and failed to provide scheduled one on one meetings with a resident's therapist as ordered. This applies to 2 of 2 residents (R83 and R52) reviewed for behavioral health services in a sample of 21. The findings include: 1. On July 10, 2024, at 10:39 AM, R83 said the facility does not offer any AA (Alcoholics Anonymous) class at the facility. R83 said there were people who wanted to go to AA, but the facility would not start it. R83 said there were no groups addressing residents who had substance abuse. R83 said when he was deciding which facility to come to, he was told the facility had substance abuse classes. R83 said psych social had purchased the AA books but no group had been started. On July 11, 2024, at 1:14 PM, R83 said he had told the Director of Psychiatric Services a few months ago. At 1:21 PM, R83 said the groups offered in the facility did not have anything to do…
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 before2024-05-24 · 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 follow its policy to administer scheduled medications as ordered. This applies to 1 of 3 residents (R1) reviewed for medication administration services and quality of care. The finding includes: R1's EMR (Electronic Medical Record) showed an admission date of 12/15/2020 with multiple diagnoses including schizoaffective disorder bipolar type, multiple sclerosis, morbid obesity, hypertensive heart disease, cystic kidney disease, anxiety, major depression, chronic pain, benign neoplasm of connective tissue of trunk, nonrheumatic mitral stenosis, migraine, fatigue, obstructive sleep apnea, and dorsalis. R1's MDS (Minimum Data Set) dated 4/18/2024 showed she was cognitively intact. On 5/23/2024 at 10:33 AM, R1 said V6 (Licensed Practical Nurse/LPN) was her nurse on 5/20/2024 from 7 PM to 7 AM and R1 did not receive her scheduled 9 PM medications. R1 said V6 came to her room twice to ask her to come out of her room to receive her medications. R1 said she tried but was having nerve pain and was unable to get out of bed. V6 said…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-05-16 · 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, interview, and record review, the facility failed to ensure maintenance and housekeeping services were provided to ensure repair of broken furniture and light fixtures, repair of floor tiles in the resident dining area and cleaning of the walls in hallways and resident rooms. This applies to all 90 residents in the facility. Findings include: The facility data sheet dated May 9, 2024, documents 90 residents in the facility. During the Environmental Tour with V6(Housekeeping Manager) on 05/09/2024 at 1:38 PM, the following was observed: 1. R2's room walls were noted to be scrapped and dirty, and a red-stained mark was present on the wall. R2's nightstand was broken. R2's face sheet showed R2 was admitted to the facility on [DATE] with diagnoses including depression, heart disease, and epilepsy. Minimum Data Set, dated [DATE] showed R2 was moderately cognitively intact. At 11:38 PM, R2 was in bed and interviewed. R2 showed his scrapped wall and the red stain and said a resident who was in his…
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 before2024-02-27 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
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 from another resident. This applies to 1 of 3 residents (R1) reviewed for physical abuse in a sample of 3. The findings include: The facility's Final Report- Resident to Resident Altercation report (from incident date 2/12/2024) showed At 4:33 PM, [R1] approached her roommate [R2] who was sitting at the dining room table and got verbally aggressive with her due to [R2] reporting her to psych-social about her walking nude in their room. [R1] then grabbed ahold of [R2's] hair and would not let go . On 2/21/24 at 2:32 PM, V6 RN (Registered Nurse) stated she was in the nurse's station and heard and saw R1 was making delusional comments and walking to the dining area. R1 was next to R2 and started saying you want to see me naked? And literally grabbed R1's hair. V6 stated it happened so quick and V6 rushed to R2 to break them apart. V6 stated she tried to grab R1 and R2 backed off and wanted to hit…
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 before2024-02-27 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services when it failed to administer a resident's monthly injection for 23 days after it was dispensed after a one-day delay in delivery. This applies to 1 of 4 residents (R4) reviewed for medications in a sample of 4. The findings include: R4's Face Sheet showed he is a [AGE] year-old resident who was admitted to the facility on [DATE]. The Face Sheet showed his diagnoses include schizoaffective disorder, bipolar type, auditory hallucinations, bipolar disorder, current episode manic severe with psychotic features, and psychosis not due to a substance or unknown physiological condition. R4's 12/18/23 Minimum Data Set showed his cognition is intact. On 2/23/24 at 8:47AM, R4 stated, I've been getting Invega (paliperidone palmitate extended-release [ER] injection) every 28 days for a whole year. The night nurse usually gives it to me at 6:00AM. R4 stated he did not receive the injection this month. R4's Active Orders…
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 before2024-01-11 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews and record reviews, the facility failed to provide a safe and sanitary environment for residents. This applies to 41 residents (R1-R3, R9-R34, R35-R46) reviewed for a sanitary environment. Findings include: 1. On 1/9/24 at 11:12 AM, mold was seen on the wood where tiles are missing and around the bathtub caulking of the bathroom shared by residents R1, R44, R45, and R46. Eight to ten tiles are missing near the faucets on the wall and internal fixtures are exposed. 2. On 1/9/24 at 10:15 AM, mold was seen above the tiles and around the bathtub caulking of the bathroom shared by residents R3, R42, and R43. Three tiles are missing, and more than three tiles are loose on the wall. 3. On 1/9/24 at 10:05 AM, mold was seen around the bathtub of the bathroom shared by residents R35, R36, R37 and R38. Part of the drywall is damaged, and a hard plastic sheet is stuck on the wall with duct tape. V4 (Director of Housekeeping) stated that there is hole in the wall that is covered by the plastic sheet. The sink in the bathroom drained very slowly. 4. On 1/9/24 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-20 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement the abuse policy by not doing a resident criminal background check within 24 hours of admission for 1 of 3 residents (R1) reviewed for abuse in the sample of 3. The findings include: The facility's Abuse policy dated 3/2022 showed, This facility will: request a Criminal History Background Check within 24 hours after admission of a new consumer . R1's Transfer/Discharge Report showed R1 was admitted to the facility on [DATE]. R1's criminal background check was dated 10/13/23 (53 days after being admitted to the facility). The report showed R1 had a criminal history. On 11/20/23 at 12:10 PM, V1 (Administrator) said background checks are to be done within 24 hours of a resident being admitted . V1 said after the request is made the results are typically e-mailed to the facility within 24 hours. V1 said there was no documentation indicating R1's background check was done within 24 hours of admission. V1 said in October they realized they did not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-08-16 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect 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 resident to resident altercations that resulted in physical abuse. This applies to 4 of 6 residents (R1, R3, R5 and R6) reviewed for abuse in the sample of 10. The findings include: 1.The facility's undated Final Report of Abuse Investigation showed on July 21, 2023, at approximately 9:00 PM, R2 became physically and verbally aggressive towards R1. The report continued to show the allegation of abuse was substantiated. The EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE]. R1's EMR showed R1 has multiple diagnoses included schizoaffective disorder, abnormalities of gait, muscle weakness, major depressive disorder, anxiety disorder, right bundle branch block and hyperlipidemia. R1's MDS (Minimum Data Set) dated July 11, 2023, showed R1 was cognitively intact and required limited assistance with dressing and personal hygiene but was independent with all other Activities of Daily Living. R1's abuse care plan-initiated…
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 · D2023-08-16 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow the facility policy for investigation procedures for allegations of resident-to-resident abuse. This applies to 4 of 6 residents (R1, R3, R5 and R6) reviewed for abuse in the sample of 10. The findings include: 1. The facility's undated Final Report of Abuse Investigation showed on July 21, 2023, at approximately 9:00 PM, R2 became physically and verbally aggressive towards R1. The report continued to show the allegation of abuse was substantiated. On August 15, 2023, at 10:30 AM, security video footage was reviewed with V8 (Human Resources). V8 said the video showed on July 21, 2023, at 8:57 PM, R2 and R7 went into R1's room. V8 said the video at 10:08 PM, showed V6 and V7 went to R1's room and tried to intervene, but R2 said it was a private conversation and R2 did not want staff present. V8 said R2 stayed in R1's room and V6 and V7 left R1's room. V8 said the video at 10:16 PM, showed R2 and R7 leave R1's room and R7 had to physically stop R2…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-06-28 · tag F0761 — failed to label and store drugs safely — widespreadEnsure 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 — the official record, unedited, may be distressing
Based on observation, interview, and record review the facility failed to ensure a multi-dose vial of tuberculin solution was labeled with an open date. This failure has the potential to affect all 93 residents residing in the facility. The findings include: The facility's Resident Census and Conditions dated 6/26/23 shows the facility census was 93. On 6/26/23 at 10:49 AM, there was an open multi-dose vial of tuberculin solution (used in testing residents for tuberculosis) that was not dated with an open date in the facility's medication refrigerator. V5 (Registered Nurse) said the vial is supposed to be dated when it is opened. The facility Medication Administration Policy effective 3/2021 shows, To ensure that the administration of medication is performed in a safe manner to prevent medication errors. Multi-dose solutions/vials labeled with date opened.
- Potential for harm · Fcited before2023-06-28 · 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 an assessment of the water system to identify where waterborne pathogens could grow and spread. This failure applies to all 93 residents in the facility reviewed for infection control. The facility also failed to ensure staff changed gloves and performed hand hygiene and failed to ensure a resident washed their hands after toileting to prevent cross contamination for 1 of 19 residents (R2) reviewed for infection control in a sample of 19. The findings include: 1. The federal form 672 completed by the facility on 6/26/23 showed the facility census was 93. On 6/27/23 at 1:50 PM, a water system assessment was requested from V6 (Maintenance Director). The facility was unable to provide a water system assessment. On 06/27/23 at 1:57 PM, V6 said he checked with corporate, and a water system assessment had not been done. The facility's Water Management Program policy (undated) showed, The Water Management Program is designed to actively identify and manage hazardous conditions that support growth and spread 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 before2023-06-28 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure a homelike environment by having gray duct tape securing the linoleum flooring on the B wing for 3 residents (R23, R63, R69) in a sample of 19 residents and 1 unsampled resident (R12) reviewed for homelike environment. The findings include: On 6/28/23 at 8:47 AM, there was gray dirty duct tape on several areas of the floor on the B wing and in the doorway of some of the rooms to secure the linoleum tiles, which were peeling loose at the edges from the floor. The dirty tape was peeling up from the tiles as well. The entry doorway to R12's room had gray dirty duct tape securing the tiles that were peeling up from the floor. There were also duct tape securing the tile coming up from the floor in front of room R12's closet area. The gray tape looks like an open boxed shape using 3 strips of tape to secure the tiles to the floor in front of the closet area. There were missing pieces of linoleum tile in the center of the hallway walk area, and the edges of the tiles were peeling up from the floor. 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 before2023-06-28 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure treatment orders were carried out for 1 of 19 residents (R82) reviewed for quality of care in the sample of 19. The findings include: On 6/26/23 at 9:42 AM, R82 was sitting in a chair at the table in the dining room. R82 said her legs have been swollen for days and days and they are not doing anything about it. R82 said she told the nurse, and she is just waiting for the stockings. R82 said her legs feel tight. R82 raised her pant leg and her right lower leg was swollen, and her ankle sock was pushing into her flesh leaving a line of indentation. R82 was not wearing any compression socks. On 6/27/23 at 9:52 AM, R82 was not wearing compression stockings. R82's Physicians Orders printed 6/27/23 show an order written on 6/19/23 with a start date of 6/20/23 for compression stockings to be put on in the morning and taken off at bedtime. R82's Minimum Data Set, dated [DATE] shows she is cognitively intact. R82's Progress Notes from…
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 · C2024-07-12 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interviews, the facility failed to post the daily staffing. This affects all 85 residents in the facility. The findings include: On 07/09/24 at 9:38 AM there was no posting of the facility's Daily Staffing at the reception desk for the current date. The posting was dated for 07/08/24. On 07/11/24 at 12:30 PM V1 (Administrator) said, I do not know why the daily census sheet for 07/09/24 was not done by 9:30 AM. It is expected that the sheet is completed and put out every morning before we come in for work. On 07/11/24 at 2:43 PM V12 (Receptionist) said she was the morning receptionist in the facility on 07/09/24. V12 said I am responsible for making sure the correct daily staffing sheet is posted every day. I am not sure why I did not have it posted for 07/09/24 at 9:38 AM. I know that it is very important to have it posted every day. I normally post it around 7:00-8:00 AM every day. The facility's Posting Direct Care Daily Staffing Numbers Policy effective date 04/2020 showed: Guideline: To provide a process to post the daily staffing numbers. Process: 1.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
$143,375 in federal fines across 1 penalty.
- $143,375 — penalty dated 2024-11-12
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
What families pay in IL
CMS lists this home as Medicaid-certified only — it can accept Medicaid for long-term care, but it is not Medicare-certified, so Medicare will not pay for a short rehabilitation (“skilled nursing”) stay here. 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 14E392. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-22, 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 →
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