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Dupage Care Center

400 N County Farm Rd, Wheaton, IL 60187 · Government - County · 366 certified beds · (630) 665-6400 Medicare & Medicaid certified

Call the home — (630) 665-6400 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Aug 20241 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (17% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • about 18% of its spending goes to commonly-owned related companies

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.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
300 S County Farm Rd · (630) 547-8045 · Call to confirm hours
Pharmacy
601 S County Farm Rd · (630) 510-1685 · Call to confirm hours
Grocery
238 N Gables Blvd · (469) 261-3071 · Call to confirm hours
Park
2126 W Roosevelt Rd · (630) 665-9100 · Typically dawn to dusk
Place of worship
0S347 Jefferson St · (630) 791-5007

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased5.6%13.4%15.4%better
Long-stay residents who lose too much weight5.1%6.3%5.4%typical
Long-stay residents with a catheter left in their bladder0.3%0.9%0.9%better
Long-stay residents with a urinary tract infection1.5%1.5%2.0%better
Long-stay residents with depressive symptoms2.7%54.2%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury0.9%3.1%3.3%better
Long-stay residents whose ability to walk worsened12.0%14.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication12.4%18.3%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%91.8%95.3%typical
Long-stay residents with pressure ulcers3.2%4.8%4.7%better
Long-stay residents with worsening bladder/bowel control13.5%20.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table17.8%21.7%17.1%typical
Short-stay residents who newly got an antipsychotic medication1.3%2.2%1.4%typical
Short-stay residents given the seasonal flu vaccine70.7%63.1%79.4%worse
Short-stay residents rehospitalized after admission16.0%26.1%22.6%better
Short-stay residents with an outpatient ER visit4.8%13.9%12.0%better
Long-stay hospitalizations per 1,000 resident days1.592.021.67typical
Long-stay outpatient ER visits per 1,000 resident days0.442.221.80better

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.

61.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 153 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

61.5%U.S. median 51.5%
Got home and stayed home
10.8%U.S. median 10.7%
Went back to hospital
53.6%U.S. median 56.6%
Met the expected recovery
0.15U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.04hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 53.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 97 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.15 therapist hours per resident per day in 2026Q1 — more than 12% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 16% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF61.5%CMS range 56.5–69.651.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.8%CMS range 7.6–13.610.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge53.6%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge54.6%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge67.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.1%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.7%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.6%CMS range 4.6–11.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.911.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

1.17
RN hours/ resident / day
0.39
LPN hours/ resident / day
2.55
Aide hours/ resident / day
4.11
Total nurse hours/ resident / day
0.86
RN hoursweekends
16.9%
Total nursing turnover
17.0%
RN turnover

How full it usually is: this home is certified for 366 beds and averages 208.8 residents a day — about 57% occupied, or roughly 157 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.11 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.17 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.55 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.53 hrs/resident/day on weekends vs 4.34 on weekdays — 19% thinner on weekends. RN hours go from 1.29 to 0.86 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 17% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

7
deficiencies at the latest standard inspection (2025-09-11)
10
at the previous standard inspection (2024-08-23)

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.

ABCDEFGHIJKL

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.

24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.

  • Actual harm · Gcited before2024-06-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 record review and interview, the facility failed to ensure two staff assisted in transferring a resident safely while using a mechanical lift. This failure resulted in R2 falling from the mechanical lift to the floor, sustaining a right tibia fracture and an occipital contusion and transfer to the emergency department. This Applies to 1 of 5 residents (R2) reviewed for falls and accidents in a sample of 9. A care plan initiated on 10/30/2023 showed that R2 needs two staff members to assist with ADLs (Activities of Daily Living), including transfers from bed to wheelchair and vice versa. The MDS (Minimum Data Set), dated 11/22/2023, showed that R2 is cognitively intact and dependent on ADLs, requiring two or more staff members to complete activities such as transfers, dressing, personal hygiene, and bathing. A review of R2's face sheet and physician's progress notes dated 01/24/2024 showed R2 was an [AGE] year-old admitted to the facility initially on 05/01/2023 with diagnoses including muscular…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-09-11 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interview and record review, the facility failed to provide residents their meal trays with others seated at the same table. This applies to 6 of 9 residents (R25, R62, R116, R153, R161, and R165) observed for dining in the sample of 35. The findings include: On September 8, 2025, at 12:09 PM during lunch meal observation on the first floor, 1 (one) North dining room, several residents were noted eating their meal when others on the same table had not received their meal tray. R160 was fed by V9 CNA (Certified Nursing Assistant) and had almost finished her meal, whereas R161 and R25 who were seated at the same table and had not received their meal trays. On a separate table in the same dining room, R68 was eating her lunch and R165 and R116 who were seated at the same table were looking on. On inquiry why R25, R116, R161, and R165 did not get their trays at the same time as other residents on the same table, V10 (Certified Nursing Restorative Aide) stated that these residents' trays are on the second cart, and it has not yet arrived. On September 8, 2025, 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-09-11 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide 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, interviews, and record review the facility failed to change a wound dressing as ordered by the physician and the facility failed to prepare medications per facility policy. This applies to 4 of 35 residents (R134, R165, R177, R195) reviewed for quality of care in the sample of 35. The findings include:1. R134's EMR (Electronic Medical Record) states R134 is 93 years-old who has multiple medical diagnoses including unspecified open wound, right lower leg, initial encounter. On September 8, 2025, at 11:25 AM, R134 was in her bedroom sitting on her wheelchair. R134's right leg was covered with elastic bandage which was stained with red and brown color discharges on the lateral area of her right leg. V23 (4th Floor Head Nurse) stated R134 has venous stasis ulcer on her right leg. On September 9, 2025, at 10:51 AM, V21 (Wound Care Nurse) rendered wound care to R134 venous stasis ulcer in the right leg. R134's Unna Boot dressing was stained with new and old dry discharge which overflowed to 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-11 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide a device or equipment for a resident with a limited range of motion to prevent potential further decrease in the range of motion (ROM). This applies to 1 of 8 residents (R9) reviewed for range of motion in the sample of 35. The findings include:R9's Face sheet shows that R9 is 75 years-old who has multiple medical diagnoses which include hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, aphasia following cerebral infarction, vascular dementia without behavioral disturbance, and weakness. MDS (Minimum Data Set) dated July 25, 2025, shows that R9 is cognitively impaired and totally dependent on staff for ADL (activities of daily living) care. On September 8, 9, and 10, from 9:30 AM through 1:30 PM, R9 was observed multiple times. R9 was in bed and non-verbal. R9's left hand noted in one position, it was slightly closed with the index and middle fingers in straight position while the ring and other fingers were bent to the joints. There was no…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to implement feeding interventions to ensure safety for a resident (R173) while eating meals. This applies to 1 (R173) of 35 of residents reviewed for accidents and supervision in the sample of 35. The findings include:R173's electronic medical record showed R173 has diagnoses that include dementia, anxiety, retention of urine, depression, cochlear implants, and dysphagia, oropharyngeal phase. R173 Minimum Data Set showed R173 to be severely cognitively impaired and dependent on staff for eating and all activities of daily living (ADL). R173's care plan dated February 11, 2025, showed that R173 has a need for hands on feeding assistance. R173 ADL care plan dated 2/26/2024 showed that R173 required purple swallow assistance- pureed diet with thick liquids, and standard swallow precaution as follows: eat only when alert, sit upright, small sips/bites, eat drink slowly.On September 8, 2025, at 11:40 AM, R173 was observed sleeping in the dining room. On September 8, 2025, at 12:37 pm observed still sleeping then V19…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-11 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to put nutrition interventions in place in a timely manner for a resident with significant weight loss.This applies to 1 of 5 residents (R14) reviewed for nutrition in the sample of 35. The findings include:The EMR (Electronic Medical Record) showed R14 was admitted to the facility on [DATE], with multiple diagnoses including sequelae of cerebral infarction, vascular dementia, and chronic obstructive pulmonary disease.R14's MDS (Minimum Data Set) dated June 13, 2025, showed R14 had severe cognitive impairment. The MDS continued to show R14 did not have a behavior of refusing care. R14's nutrition care plan dated September 26, 2023, showed [R14] has potential nutritional problem related to vascular dementia, depression, anxiety may affect meal intakes. Diagnoses sequelae of cerebral infarction, hypertension. Diagnosis chronic obstructive pulmonary disease. Diagnosis hypothyroidism. The care plan continued to show multiple interventions dated September 26,…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-11 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to follow physician order for medication administration. There were 25 medication opportunities with 2 errors, resulting to 7.69% error rate. This applies to 2 of the 8 residents (R9, R13) reviewed for medication administration in the sample of 35. The finding include:1. On September 9, 2025, at 9:44 AM, V17 (Nurse) administered multiple medications to R13 including Esomeprazole via gastric tube (g-tube). The Esomeprazole cup remained with decent amount of medication residuals after V17 completed the medication administration. R13's Medication Administration Record (MAR) dated September 2025 shows to give Esomeprazole 20 mg via g-tube once daily for GERD (gastroesophageal reflux disease). 2. On September 9, 2025, at 1:39 PM, V18 (Nurse) administered Rifampin oral suspension to R9. The thick Rifampin liquid suspension was mixed with water when V18 administered it to R9 via g-tube. However, V18 did not give the full dose of this antibiotic because there were still residues of this medication left from the medicine…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-11 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a resident with a pneumococcal vaccine.This applies to 1 of 5 residents (R34) reviewed for immunizations in the sample of 35. The findings include:The EMR (Electronic Medical Record) showed R34 was a [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including dementia, type 2 diabetes mellitus, chronic kidney disease, and ventricular tachycardia.R34's Pneumococcal Vaccine Consent/Declination Form showed on June 23, 2025, R34's POA (Power of Attorney) consented for R34 to receive the pneumococcal vaccine.R34's Immunization Report dated September 10, 2025, showed R34 did not receive the pneumococcal vaccine until September 9, 2025.On September 10, 2025, at 1:17 PM, V2 (DON/Director of Nursing) said R34 received the vaccine on September 9, 2025, after V5 (ADON/Assistant Director of Nursing) started compiling the requested vaccination information, V5 saw R34 did not receive the pneumococcal vaccine so the facility…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-08-23 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 properly label/date/seal/store items, remove expired items, and perform hand hygiene while in the facility kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 8/20/24 documents that the total census was 211 residents. On 8/22/24 at 1:16 PM, V39 (ADON/Assistant Director of Nursing) said there are 6 NPO (Nothing by Mouth) residents; all other residents eat from the facility kitchen. On 8/21/24 starting at 10:19 AM, V23 (Chef) was observed pureeing lunch items. After V23 pureed the chicken, she removed her gloves, pulled the garbage can out from under the counter with her bare left hand (while touching the rim of the garbage can) and threw away her gloves with her right hand. V23 then put on a new pair of gloves and did not wash her hands after touching the garbage can. V23 then put some of 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-23 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to date and discard as indicated insulin vials when opened. The facility failed to store medications in their original packaging until they were administered. This applies to 8 of 8 residents reviewed (R104, R96, R160, R197, R75, R121, R146, R73) for medication storage in the sample of 37. Findings include: 1. On 8/20/2024 at 3:40 PM, V9 (RN/Registered Nurse) was asked to check the fourth floor's medication room for medication storage. V9 said R73's opened and filled Levemir insulin vial was not dated with the open date. V9 said R146's opened and filled Fiasp insulin vial was not dated with the open date. V9 said R121's opened and filled Lantus insulin vial was not dated with the open date. V9 said R75's opened and filled Fiasp and Glargine insulin vials were not dated with the open dates. V9 said insulin vials should be dated when they are opened for proper medication storage. On 8/20/2024 at 4:40 PM, V11's (Licensed Practical Nurse/LPN) medication cart was checked for medication storage. V11 said R197's opened…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-23 · tag F0880 — failed to prevent and control infections — pattern
    Provide 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 use appropriate PPE (Personal Protective Equipment) for a resident on EBP (Enhanced Barrier Precautions) and failed to do proper hand hygiene to prevent the spread of infection. This applies to 5 of 5 residents (R68, R41, R155, R364, R365) reviewed for infection control in a sample of 37. The findings include: 1. On 8/20/24 at 11:23 AM, V27 (CNA/Certified Nurse Assistant) was providing personal hygiene and incontinence care for R68. R68 was on EBP due to having a G-Tube (Gastrostomy Tube). V27 applied a gown and gloves and provided incontinence care to R68, who had stool and urine in her disposable brief. V27 wiped the urine and stool off R68, then took a new incontinence brief and applied it under R68. V27 did not change her gloves or perform hand hygiene when going from the dirty brief to the clean brief. At 11:48 AM, V27 left R68's room without removing the PPE to throw the dirty linen bag in a container in the hallway. At 11:49 AM,…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · Dcited before2024-08-23 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to place call lights within reach of residents. This applies to 3 of 3 residents (R145, R168, R155) reviewed for accommodation of needs in a sample of 37. The findings include: 1. On August 20, 2024 at 12:46 PM, R145 was brought back to her room with the assistance of V24 (CNA/Certified Nurse Assistant). V24 wheeled R145 towards the foot of the bed and left the resident in her wheelchair at the foot of the bed. R145's call light was lying across the center of the bed, out of reach of the resident. When asked, R145 said she needed to press the call light to ask for help. R145 tried to propel herself to reach the call light but was not able to reach her call light. R145 asked R168 to reach for her call light, and R168 was not able to reach the call light. At 12:54 PM, R145 was still attempting to reach for her call light but was unable to. R145's face sheet showed R145 was admitted with diagnoses including repeated falls, wedge compression…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-23 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to report allegations of verbal abuse within 24 hours. This applies to 1 of 2 residents (R141) reviewed for abuse in a sample of 37. Findings include: R141 admitted to the facility on [DATE] with diagnoses that includes paraplegia, neuralgia, cramp / spasm, diverticulosis, hypertension, depression, anxiety, and insomnia. R141's MDS (Minimum Data Set) dated 7/17/24 shows he is cognitively intact with a BIMS (Brief Interview for Mental Status Score) of 15. On 8/20/24 at 11:48 AM, R141 stated V40, CNA (Certified Nurse Aide) verbally abused him by saying he was a bother and no other CNAs wanted to work with him. R141 stated, V2 DON (Director of Nursing) and V5 Social Services Manager were aware of his allegations from the previous week. On 8/20/24 at 12:10 PM, V5 stated she spoke to R141 on 8/17/24 regarding removing V40 CNA from his care team. V5 stated R141 did not like the way V40 positioned him in the wheelchair. V5 stated she did not ask R141 details as…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-23 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 observations, interviews, and record reviews, the facility failed to properly monitor, assess and treat a resident who is at risk for potential pressure ulcers. The facility also failed to properly monitor, and assess 1 resident who is unable to reposition themselves. This applies to 2 of 2 residents (R104 and R155) reviewed for quality of care. Findings include: 1. R104 is a [AGE] year old female admitted to the facility on [DATE] with diagnosis including chronic kidney disease stage 3, type 2 diabetes, unspecified mental disorder, schizoaffective disorder, urinary tract infection, E coli, altered mental status, ataxic gait, difficult in walking, history of falls, pressure ulcer of sacral region stage 3, pressure ulcers of left buttock unstageable, metabolic encephalopathy, depression, cognitive communication deficit, hyperlipidemia, muscle spasms, acquired absence of digestive tract, artificial right hip and anxiety. On 8/20/24 at 11:31 AM, R104 was observed in her bed on her back and again at 12:10…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to safely transfer residents using a gait belt. This applies to 2 of 2 residents (R68, R191) reviewed for mobility in a sample of 37. The findings include: 1. On August 21, 2024 at 2:11 PM, V25 (CNA/Certified Nurse Assistant) and V41 (Restorative Aide) assisted R68 from a lying to a sitting position. V25 applies a gait belt around R68's waist and then V25 and V41 assists R68 into a standing position, with V25 pulling R68 up by her pants. At 2:11 PM, V25 pulled R68 further back into her wheelchair using her pants instead of the gait belt. R68's face sheet showed she was admitted to the facility with diagnoses including dysphagia, gastrostomy status, failure to thrive, cognitive communication deficit, osteoporosis, and a history of falling. R68's MDS (Minimum Data Set) dated August 14, 2024 showed R68 had severe cognitive impairments and was dependent on staff to transfer from lying to sitting on side of bed, sit to stand, and bed to chair…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-23 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to offer hydration fluids for a resident at risk for dehydration. This applies to 1 of 2 residents (R30) reviewed for hydration in the sample of 37. Findings include: R30's EMR (Electronic Medical Record) showed R30 had multiple diagnoses including recurrent urinary tract infections, a disorder of the kidney and ureter, neuromuscular dysfunction bladder, urinary retention, constipation, and parkinsonism. R30's MDS (Minimum Data Set) dated 5/09/2024 showed she was cognitively intact. R30's MDS continued to show she was dependent on facility staff for assistance with feeding including drinking liquids. On 8/20/2024 at 10:57 AM, R30 was in bed and said she was not getting enough water. R30 said she was having urinary discomfort and was waiting for her urine results. R30 had no water at the bedside but had a tub of thickener mixing powder. On 8/21/2024 at 11:30 AM, R30 was in bed with no water at the bedside. At 12:30 PM, R30 said she wanted 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-23 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    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 change, date, and label a feed tubing for an enteral feed for a resident with a gastrostomy tube (G-tube). This applies to 1 of 1 (R68) resident reviewed for gastrostomy tubes in a sample of 37. The findings include: On August 20, 2024 at 11:23 am, R68 was connected to her feeding via the gastrostomy tube and was receiving it at a rate of 50 milliliters per hour. R68's bottle of formula was dated August 19, 2024 at 4 PM and the tubing was dated August 15, 2024 at 9:53 PM. On August 21, 2024 at 11:32 AM, R68's feed tubing was not labeled or dated. On August 22, 2024 at 11:34 AM, V26 (RN/Registered Nurse) said the G-tube pump tubing was changed whenever a bottle was opened. V26 said the tubing should not be used for more than 24 hours. V26 also said the tubing needed to be dated and labeled. On August 22, 2024 at 1:16 PM, V35 (RN) said when the staff start a feeding, all the equipment needs to be brand new. V35 said the tubing and bottle need to be changed every 24 hours, or more frequently, depending on when…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-23 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide documentation of monthly medication reviews and obtain a documented physician response to pharmacy recommendations. This applies to 1 of 5 residents (R141) reviewed for unnecessary mediations in a sample of 37. Findings include: R141 admitted to the facility on [DATE] with diagnoses that includes paraplegia, neuralgia, cramp / spasm, diverticulosis, hypertension, depression, anxiety, and insomnia. R141's MDS (Minimum Data Set) dated 7/17/24 shows he is cognitively intact with a BIMS (Brief Interview for Mental Status Score) of 15. On 8/21/24 at 3:47 PM, V7 Pharmacy Manager stated he did not have documentation of the medication review done on 3/16/24 or 6/24/24. Pharmacy recommendations made on 11/27/23 did not have a physician response. On 8/22/24 at 9:53 AM, V7 Pharmacy Manager stated pharmacy recommendations are sent to the units for the physician to address when they round. Nursing is responsible for following up with the physician to address…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-26 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor 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 observation, interview, and record review, the facility failed to provide dignity for 5 of 5 residents (R19, R61, R72, R79, R128) reviewed for dignity in the sample of 36. The findings include: On 10/26/23 at 10:00 AM, V16 (unit secretary) was observed paging call light assistance over an intercom. She announced the room and bed number. At 10:22 AM she announced bathroom assistance with the room number. The admission record for R128 shows he was admitted to the facility 6/29/16. His 8/24/23 quarterly assessment shows him to be cognitively intact. On 10/26/23 at 11:21 AM, R128 said the overhead paging has been brought up before, and he was told it was going to be phased out. It is embarrassing when someone says toileting assist and their room number or their name. All of the shifts use the paging system. He said the secretary will announce who needs bathroom assistance and it is embarrassing for those that are incontinent or in the bathroom, everyone does not need to know that information. The admission…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-26 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Observation, Interview and Record Review the facility failed to serve residents trays at an appetizing temperature for eight residents (R5, R12, R128, R119, R19, R79, R72, & R61) outside of the sample. The findings include: On 10/24/23 at 11:17 AM, the first tray cart containing lunch trays was delivered to the third floor. Residents were sitting in the common area at tables. Staff were not passing any of the lunch trays. At 11:37 AM, the second tray cart containing lunch trays was delivered to the third floor. V7 CNA (Certified Nursing Assistant) took a rolling cart over to the first tray cart, opened the doors to look for certain trays and placed them on her rolling cart. V7 went to the second tray cart, opened the doors to look for certain trays and placed them on her rolling cart. V7 took 4 resident trays and walked down the hall. At 11:42 AM, V8 CNA started serving lunch trays. V9 CNA opened the first tray cart, removed a couple of trays, left the doors open and went to the second cart to look for…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-26 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the call light system was in reach for 1 of 1 resident (R42) reviewed for call lights not in reach in the sample of 36. The findings include: R42's admission Record, printed by the facility on 10/26/23, showed she had diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting her left side (left-sided paralysis and weakness following a stroke), vascular dementia, visual loss in her left eye, glaucoma, osteoarthritis. The facility assessment dated [DATE], showed R42 had severe cognitive impairment and was dependent on staff for eating, toileting, bathing, personal hygiene, and transfers. The assessment showed R42 was always incontinent of bowel and bladder. R42's care plan dated 12/1/21, showed she has an ADL (activities of daily living) self-care deficit related to activity intolerance, hemiplegia, impaired balance and stroke. One of the interventions in place was Encourage the resident to use bell 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident was transferred in a safe manner for 2 of 5 residents (R69, R87) reviewed for falls in the sample of 36. The findings include: 1. R69's face sheet showed a [AGE] year old male with diagnosis of diabetes, osteoarthritis of the knee, chronic kidney disease, bilateral artificial hip joints, muscle weakness, and malignant neoplasm of the prostate. R69's 8/30/23 facility assessment showed he was cognitively intact and required extensive assistance of one person to physically assist with transfer, bed mobility, and toilet use. R69's care plan showed he was at risk for falls. On 10/24/23 at 1:15 PM, V6 Certified Nursing Assistant (CNA) applied the mechanical stand lift transfer harness to R69's upper body and attached it to the lift. Once R69 was off the toilet and upright (with knees bent), the safety belt was noted to be very loose. This surveyor reached to the belt to show the excess slack in the belt in relation to R69'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-26 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure incontinence care was performed in a manner to prevent cross contamination and failed to ensure urinary drainage bags were off the floor for 3 of 3 residents (R28, R200, R22) reviewed for incontinence care in the sample of 36. The findings include: 1. R28's face sheet printed on 10/26/23 showed diagnoses including, but not limited to, depression, atrial fibrillation, hydronephrosis, and obstructive uropathy (urine accumulation in kidney). R28's facility assessment dated [DATE] showed staff assistance required for toilet use, and always incontinent of urine and bowel. R28's care plan showed a focus area related to at risk for complications from removal of right ureteral stone on 10/18/23 with recent complicated urinary tract infection and hydronephrosis, cystoscopy, right ureteral stent placement on 9/27/23. R28's physician orders showed an order start dated on 10/18/23 for: Cedfinir capsule (antibiotic) 300 milligram two times daily…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-19 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a resident was properly identified prior to medication administration to prevent medication errors as per facility policy. This applies to 1 of 3 residents (R1) reviewed for medication errors in a sample of 7. The findings include: MDS (Minimum Data Set), data 8/30/23, shows R1 was cognitively intact. R1's MAR (Medication Administration Sheet), dated 9/1/23 to 9/30/23, shows R1 had physician orders for the following medications during the month of 9/2023: Oyster Shell Calcium, Ergocalciferol, Flomax, Gabapentin, Glipizide, Levothyroxine, Loratadine, Melatonin, Metoprolol Extended Release, Pravastatin Sodium, Diclofenac gel, albuterol, docusate, guaifenesisn, and acetaminophen. On 10/18/23 at 12:47 PM, R1 was sitting in a wheelchair in a small dining room and was alert, oriented, communicative, and well groomed. R1 stated, I feel OK now! R1 stated on 9/26/23, R1 was approached by V3 (Registered Nurse) who stated she was going to provide R1 his due medications. R1 stated he usually received medications at that 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
DUPAGE COUNTYOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 08/08/1966
BAKER TILLY US LLPOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2016
SYMBRIA REHAB, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2017
BERMAN, SHAUNAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/19/2013
BOHAN, HEIDIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/28/2021
BORSKE, DIANEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/04/2023
BUTLER, ELIZABETHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/10/2022
CERNY, KARENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/21/2014
CHADWICK, JANELLEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/24/2017
COBLENTZ, SUSANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFNO DATE PROVIDED
GALLETA, ARLEENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/06/2023
KLIMEK, JONATHANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/14/2021
LOMADILLA, ANNABELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/27/2019
MEMISHA, INVAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/28/2021
MIELE, ANGELOIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2020
PATEL, VINITIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/15/2008
PLATA, MARIOIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/15/2008
RAJAGOPAL, VISALAKSHIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/16/2013
ROMERO, RHONDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/06/2023
CLIFTONLARSONALLEN LLPOrganizationADP OF THE SNFsince 03/20/2025

CMS files one row per role, so the 39 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted.

4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$35.0M
Net patient revenuemost recent cost report
-2.5%
Operating marginrevenue minus expenses
$6.5M
Related-party expense18% of expenses
Who pays — share of resident-days
Medicaid 17%Medicare 4%Other / private 79%

This home reported $6.5M paid to related parties — landlords or management companies under common ownership — equal to about 18% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$460per resident / day
operating cost
$13,971per month
≈ monthly operating cost
$448per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in IL

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.

Typical monthly cost in Illinois
$8,304/mo
Nursing home (semi-private)
$9,216/mo
Nursing home (private)
$6,219/mo
Assisted living

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 145050. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-11, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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