Chateau Nrsg & Rehab Center
7050 Madison Street, Willowbrook, IL 60521 · For profit - Limited Liability company · 150 certified beds · (630) 323-6380 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2024
- 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 a citation for mishandling residents’ money or property (F0567)
- it has 4 actual-harm citations
- a high number of inspection citations overall (35) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $75,389 in federal fines (most recent 2026-04-27)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 3 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 | 10.2% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.5% | 6.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.1% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 92.4% | 54.2% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 5.2% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 9.4% | 14.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 22.3% | 18.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 86.1% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.4% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 14.9% | 20.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.2% | 21.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 6.0% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 84.0% | 63.1% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 13.9% | 26.1% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 12.7% | 13.9% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.00 | 2.02 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.15 | 2.22 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
45.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 65 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 37.1% 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 35 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.23 therapist hours per resident per day in 2026Q1 — more than 29% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 | 45.5%CMS range 35.5–58.6 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.8%CMS range 7.2–14.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 37.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 51.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 40.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.7% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 5.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 9.5%CMS range 5.5–15.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.28 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 150 beds and averages 121.9 residents a day — about 81% occupied, or roughly 28 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.21 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.85 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.87 hrs/resident/day on weekends vs 3.34 on weekdays — 14% thinner on weekends. RN hours go from 0.64 to 0.48 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
35 citations, most serious first. The 14 most serious are shown; the remaining 21 are one tap away and print in full.
- Actual harm · Gcited before2026-04-27 · 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 comprehensively assess a resident for post-fall complications, including failing to identify worsening acute pain and failing to obtain timely diagnostics. This failure resulted in a resident receiving delayed care for his left hip fracture.This applies to 1 of 3 residents (R1) reviewed for quality of care in a sample of 5. The findings include:R1's 2/17/26 progress note from 5:30 AM showed R1 .was noted on the floor in front of his wheelchair in an upright sitting position, sustaining a skin tear to the left elbow. When asked what happened, (R1) said that he was reaching for papers on the chair and slid out of the wheelchair. Left elbow cleansed and dressing applied. Wife made aware and also NP [Nurse Practitioner] aware of fall.On 4/23/26 at 10:12 AM, V3 ADON (Assistant Director of Nursing) stated that R1 had a fall on 2/17/26 at 5:30 AM. V3 stated R1 got up from his wheelchair and ambulated with his rolling walker to the bed without assistance. V3 stated R1 got up from his bed, tripped over his leg rest and fell 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.
- Actual harm · Gcited before2025-03-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to prevent a resident from falling off the bed during care resulting in R1 sustaining a femur fracture. This applies to 1 of 3 residents (R1) reviewed for falls in a sample of 3. The findings include: On March 11, 2025, at 10:39 AM, V3 (CNA/Certified Nurse Assistant) said on February 24, 2025, she had gone to R1's room to change R1's incontinence brief. V3 said R1 was a one-assist from staff and could help her with some things. V3 said when she walked into R1's room to the left side of the bed, she observed R1's body was closer to the right side of the bed, versus being centered. V3 said she flattened R1's bed out and picked up her draw sheet from underneath her left side and told her to turn towards the right, and as V3 turned R1 away from her, R1's legs started falling off the bed out of the right side. V3 said she tried to catch them, but it was too late, and R1 had fallen out of the bed onto the ground. V3 said she ran and notified the nurse. V3 said R1 was on an air mattress, which should have had bolsters…
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 before2025-01-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure fall interventions were in place for a resident who is at high risk for falls for 1 of 4 residents (R1) reviewed for safety in the sample of 6. This failure resulted in R1 falling out of bed and sustaining a laceration to her forehead requiring stitches. The findings include: R1's Minimum Data Set assessment dated [DATE] shows that her cognition is impaired and R1 has had one fall with no injury and two or more falls with injury since her prior assessment. On 1/21/25 at 11:11 AM, V3, Certified Nursing Assistant (CNA) said that on 1/3/25 he went into R1's room to get her up for the morning. V3 said that he removed her fall mat from the floor and removed her bed bolsters from the bed in order to provide incontinence care. V3 said that after incontinence care was provided, he lowered the bed and went to get the mechanical lift sling. V3 said that when he turned back around, he saw R1 with her upper body out of the bed and her head on the floor. V3…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2022-09-22 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to identify areas of pressure before becoming unstageable and failed to change the dressings as ordered by the Physician. This applies to three of eight residents (R49, R38, R81) in the sample of 24 reviewed for pressure. This failure resulted in two residents (R49) and (R38) developing unstageable pressure injuries. The findings include: 1. The facility face sheet for R49 shows diagnosis to include chronic obstructive pulmonary disease, dementia, and hemiplegia. The facility assessment dated [DATE] shows her to have severe cognitive impairment and requires extensive assistance with bed mobility. The wound management detail report for R49 shows a pressure ulcer to the right heel was first identified on 6/28/2022. At that time the wound measured 4 by 3 centimeters with necrotic tissue present. The wound was not staged until 7/14/2022 and was staged as unstageable with slough and eschar. The care plan for R49 dated 6/27/2022 shows interventions…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-27 · tag F0776 — isolatedProvide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
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 timely hip X-ray was obtained for a resident after a fall. This applies to 1 of 3 residents (R1) reviewed for diagnostic services in a sample of 5.The findings include:R1's 2/17/26 progress note from 5:30 AM showed .noted on the floor in front of his wheelchair in an upright sitting position, sustaining a skin tear to the left elbow. When asked what happened, (R1) said that he was reaching for papers on the chair and slid out of the wheelchair. Left elbow cleansed and dressing applied. Wife made aware and also NP (Nurse Practitioner) aware of fall .R1's 2/17/26 progress note from 1:57 PM (written by V6-Nurse Practitioner/NP) showed The patient had a fall on 2/17/26. The staff reported that (R1) was noted on the floor in front of the wheelchair in an upright sitting position, sustaining a skin tear to the left elbow. The examiner assessed the resident. (R1) stated that he was sitting on the edge of the bed and used his walker to reach papers on a chair and fell. (R1) indicates pain in the left hip. (R1) is unable…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-11 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to follow its abuse prevention policy by not protecting a resident from verbal abuse from staff. This applies to 1 of 3 residents (R1) reviewed for verbal Abuse in a sample of 3. The Findings include: R1 is a [AGE] year-old female admitted on [DATE] with an admitting diagnosis including vascular dementia. A review of the Minimum Data Set (MDS) dated [DATE] documents that R1 has severe cognitive impairment. On 12/10/24 at 10:10 AM, V5 (Registered Nurse / RN) stated, When I came back from vacation on 12/4/24, I heard from V6 (RN) and V7 (Licensed Practical Nurse / LPN) about the verbal abuse from V4 to R1. R1 is very confused, and I heard V4 called R1 something with the 'f_ _ k' word. On 12/10/24 at 10:13 AM, R1 stated in the presence of V5 (Registered Nurse / RN), It's been a while since someone called me with the 'F' word. But I don't know who or when. On 12/10/24 at 10:15 AM, V7 stated, On 11/20/24 during lunchtime, I was sitting in the nurse's station…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-11 · tag 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to follow its abuse prevention policy by not reporting a verbal abuse allegation to state agency. This applies to 1 of 3 residents (R1) reviewed for abuse reporting in a sample of 3. The Findings include: R1 is a [AGE] year-old female admitted on [DATE] with an admitting diagnosis including vascular dementia. A review of the Minimum Data Set (MDS) dated [DATE] documents that R1 has severe cognitive impairment. On 12/10/24 at 10:10 AM, V5 (Registered Nurse / RN) stated, When I came back from vacation on 12/4/24, I heard from V6 (RN) and V7 (Licensed Practical Nurse / LPN) about the verbal Abuse from V4 to R1. R1 is very confused, and I heard V4 called R1 something with the 'f_ _ k' word. On 12/10/24 at 10:15 AM, V7 stated, On 11/20/24 during lunchtime, I was sitting in the nurse's station and could see R1 in the dining room. V4 took R1's tray away, and R1 raised her hand and hit the tray, causing the coffee cup to fall off the tray along with other food…
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 · D2024-09-24 · 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 ensure that a personal mail with a gift check was given to the resident whom it was addressed to, and not deposited to the transferring account intended for payment of the resident's room and board. This applies to 1 of 3 residents (R1) reviewed for personal funds in the sample of 3. The findings include: Face sheet and Minimum Data Set (MDS) dated [DATE], shows that R1 is 83 years-old who is alert and oriented. R1 was independent to some of her activities of daily living (ADL) care and needs supervision to some. R1 was admitted to the facility on [DATE]. On September 23, 2024, at 10:17 AM, R1 said that she has been living in this facility for almost 2 years. R1 receives her husband's pension from the police department, and she has social security benefits as well. These checks go straight to the facility for payment of her room, board, and treatment. In addition, R1 usually receives a check every Christmas from the Policemen's Annuity and Benefit Fund…
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 before2024-08-08 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to store, prepare, and serve food in a sanitary manner. This has the potential to affect all 116 residents that receive food prepared in the facility kitchen. The findings include: Facility provided information that the census on August 5, 2024, was 117 residents with one resident on NPO (nothing by mouth) status. On August 5, 2024, at 9:17 AM, during initial tour of the kitchen the following observations were made: At the 3-compartment sink, used for wash, rinse and sanitizing dishes, dirty dishes were seen in the sanitizing sink. V6 (Dietary Aide) was seen washing the dishes in the middle sink, which should be used for rinsing dishes. V6 stated that she is going to fill the sanitizing sink with sanitizer. V6 then removed the dirty pans from the sanitizing sink and filled it with water mixed with sanitizer. It was noted that the sanitizing well still had food debris from the dirty pans and also had dirty rags in it. When notified that the sanitizer was contaminated, V6 cleaned and refilled the sanitizing sink…
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 before2024-08-08 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assist residents identified as needing assistance with personal hygiene. This applies to 4 of 5 residents (R20, R85, R100 and R108) reviewed for ADLs (activities of daily living) in the sample of 25. The findings include: 1. R108 had multiple diagnoses including, dementia with other behavioral disturbance and weakness, based on the face sheet. R108's quarterly MDS (minimum data set) dated July 23, 2024, showed that the resident was severely impaired with cognitive skills for daily decision making. The same MDS showed that R108 was totally dependent on the staff with her ADLs including upper body dressing and personal hygiene. On August 5, 2024, at 11:36 AM, R108 was sitting in her reclining wheelchair inside the unit dining/activity room. R108 was alert but confused. R108's fingernails were short with black substances underneath. R108 was observed sticking her fingers inside her mouth. V14 (CNA/Certified Nursing Assistant) was present…
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 · E2024-08-08 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure that the dietary staff followed the approved recipe for chef salad. This applies to 8 of 8 (R25, R26, R27, R6, R84, R91, R101, R113) residents reviewed for dining in the sample of 25. The findings include: Facility Spring/Summer 2024 (Week 4) Menu on Thursday [August 1, 2024] showed Chef's salad, seasonal fruit, baked fresh roll, cinnamon apple sauce, margarine. On August 5, 2024, at 3:23 PM, R6 stated The whole place got a bowl container of some kind of lettuce with no meat or cheese. There was no bread roll served with it. I ate in the dining room, and everybody was startled. I did not ask for anything else as it was night-time, and the people (from kitchen) had cleaned up and left. On August 5, 2024, at 3:22 PM, R26 stated Last week some time at dinner I got a bowl of lettuce with ranch dressing and no meat. I ate in my room and did not say anything. On August 5, 2024, at 3:18 PM, R91 stated Sometime for dinner last week we got a bowl of shredded lettuce with no meat. I thought 'What is this?' I felt like a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-08-08 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to follow standard infection control practices with regards to hand hygiene and gloving during provisions of incontinence care. This applies to 5 of 25 (R20, R62, R64, R80, R85) residents reviewed for infection control in the sample of 25. The findings include: 1. On August 6, 2024, at 11:25 AM, V24 and V26 (Both Certified Nursing Assistants/CNAs) rendered peri-care to R80. V24 cleaned R80's perineum from front to back, then she placed a clean incontinence brief underneath R80 while wearing same gloves. V24 then, changed her gloves without performing hand hygiene and continued to reposition R80. V24 then handled the indwelling urinary catheter bag and straightened clean bed linens without performing hand hygiene in between tasks. 2. On August 6, 2024, at 1:39 PM, V25 (CNA) assisted R62 to the toilet where R62 voided and had a bowel movement. After R62 used the toilet, she wiped her frontal perineum, then V25 assisted R62 to stand up and cleaned R62's back perineum. V25 wiped R62's rectum multiple times, pulled…
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 · D2024-08-08 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure that the indwelling urinary catheter was not positioned above the resident's bladder and failed to clean the catheter tube during incontinence care. This applies to 2 of 4 (R64 and R80) residents reviewed for peri-care and catheter care in the sample of 25. The findings include: 1. R80's face sheet shows that R80 has multiple medical diagnoses which includes Benign Prostatic Hyperplasia (BPH) with lower urinary tract symptoms. On August 6, 2024, at 11:25 AM, R80 was resting in bed, he had an indwelling urinary catheter with the urinary bag hanging on the left side of the bed. V24 and V26 (Both Certified Nursing Assistants/CNA) rendered peri-care to R80. V24 cleaned R80's perineum from front to back. V24 cleaned the tip of R80's penis, however, she but did not clean the catheter tube. When V24 and V26 repositioned R80 on his right side, V24 lifted and handed the urinary bag to V26 to place it on the right side of the bed. The urinary bag was lifted high above the bladder which made the urine inside the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-08 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure 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 check the placement of the gastrostomy tube (g-tube) prior to administration of medication. This applies to 1 of 2 residents (R80) reviewed for gastrostomy tube in the sample of 25. The findings include: On August 7, 2024, at 9:47 AM, V29 (Nurse) administered Hydrocodone-Acetaminophen 5-325 milligram tablet to R80 via g-tube. V29 flushed R80's g-tube with 60 milliliters (ml) of water and then administered Hydrocodone-Acetaminophen. Then V29 flushed the g-tube again with 60 ml of water. V29 did not check the placement of the g-tube prior to administering the medication. V29 stated that she forgot to do it. On August 7, 2024, at 10:51 AM, V28 (Assistant Director of Nursing/ADON) stated that when giving g-tube medication, the staff should check for the placement of the g-tube either by aspiration of residual or auscultation with stethoscope. This is to make sure that the medication is going into the right place. One of R80's g-tube care plan interventions dated July 15, 2024, shows Check placement and patency 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.
Show the remaining 21 citations
- Potential for harm · D2024-08-08 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to recognize, evaluate and manage a resident's pain during care. This applies to 1 of 1 resident (R24) reviewed for pain management in the sample of 25. The findings include: R24 had multiple diagnoses including, senile degeneration of the brain and dementia without behavioral disturbance, based on the face sheet. R24's quarterly MDS (minimum data set) dated May 9, 2024, showed that the resident was severely impaired with cognition and required total assistance from the staff with her ADLs (activities of daily living). On August 5, 2024, at 10:31 AM, R24's door was closed, and the resident could be heard from outside of the door, moaning. Upon entering R24's room, the resident was in bed and was moaning. R24 was confused and could not verbalize pain when asked. V15 (CNA/Certified Nursing Assistant) and V17 (CNA) stated that they just finished providing morning care to R24. According to V15, R24 would be moaning during provision of care. V15 was not aware if R24 had received any pain medication prior to them…
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 before2024-06-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide timely incontinence care for 2 of 5 residents (R1 and R2) reviewed for activities of daily living. Findings include: 1.R1 is a [AGE] year-old with diagnoses including pressure ulcer sacral region stage 3, diaper dermatitis, moderate protein-calorie malnutrition, irritable bowel syndrome with diarrhea, and anemia. The care plan dated 04/30/2024 showed that R1 has a limited ability to participate in daily care activities and has an impairment of skin integrity related to incontinent care. The admission MDS (Minimum Data Set) assessment, dated 04/10/2024, showed the resident was cognitively intact, and R1 was always incontinent of bladder and bowel and required extensive assistance from staff for incontinent care. During an observation and interview on 06/11/2024 at 11:30 a.m., R1 was lying on her back and was upset and tearful. R1 said she had a bowel movement at 10:00 a.m., and one of the Nursing Assistants said she needed another…
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 · E2023-09-29 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably 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 keep call lights accessible to dependent residents. This applies to 7 of 7 residents (R23, R28, R38, R41, R83, R91, and R103) reviewed for accommodation of needs in a sample of 32. The findings include: 1. R91's face sheet showed the following diagnoses of acute respiratory disease, vascular dementia, anxiety disorder, abnormalities with gait and mobility and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R91's MDS dated [DATE] showed that R91's cognition is moderately impaired; R91 needs extensive assistance with two or more person physical assist with bed mobility, toilet use and personal hygiene; total dependence with two or more person physical assist with transfer. R91's care plan (start date 1/21/23) showed that R91 is at risk for falling as a result of decreased endurance, increased weakness with intervention to keep call light in reach at all times. On 9/27/23 at 9:28 AM, R91 was sitting up in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-09-29 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide incontinent care, facial hair grooming, and nail trimming/grooming to dependent residents. This applies to 5 of 7 residents (R6, R36, R41, R58, and R103) reviewed for activities of daily living (ADL) in a sample of 32. The findings include: 1. R41 is a [AGE] year-old female with mild cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. The MDS also documents one-person extensive assistance with toilet use and personal hygiene. On 9/27/23 at 9:38 AM, R41 was sleeping with a strong urine odor on her bed. R41 stated that she hasn't been changed yet. On 9/27/23 at 9:41 AM, V4 (Certified Nursing Assistant/CNA) checked on R41, and R41 was observed with an incontinence pull-up outside of an incontinent brief, and a bigger pad inside the incontinent brief, soaked in urine. 09/27/23 09:41 AM V4 stated, I changed R41 at around 6:30 AM when I started (three hours earlier). I have 11 residents, and incontinent care should be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-09-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 supervise residents with aspiration precautions during meals, failed to implement fall interventions, failed to secure oxygen tanks in resident rooms, failed to safely position a resident during incontinence care, and failed to safely transfer residents. This applies to 12 of 12 residents (R2, R8, R14, R24, R33, R43, R50, R55, R70, R80, R91, and R99) reviewed for accidents and supervision in a sample of 32. The findings include: 1. The EMR (Electronic Medical Record) showed R2 was admitted to the facility on [DATE], with multiple diagnoses including dysphagia, protein-calorie malnutrition, multiple sclerosis, dementia, acute respiratory failure, and weakness. The MDS (Minimum Data Set) dated 7/19/2023 showed R2 was cognitively intact. The MDS continued to show R2 required supervision assistance of one person physical assistance with eating and extensive assistance of one to two person physical assistance for bed mobility and transfers…
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 before2023-09-29 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to administer medications as ordered (at ordered routes or per the schedule). There were 29 opportunities with 7 errors resulting in a 24.1% error rate. This applies to 4 of 4 residents (R51, R24, R43, R16) observed in the medication pass. The findings include: 1. On 9/27/23 at 08:34 AM during medication pass, V12 (RN/Registered Nurse) was preparing and administering medications for R51. V12 took R51's Aspirin 81 mg (Milligram) chewable tablet and put it in the medication cup, along with R51's other medication. At 08:48 AM, V12 gave R51 her medications and R51 swallowed her medication. R51 did not chew her chewable aspirin. R51's face sheet shows R51 was admitted to the facility with diagnoses including aphasia following stroke, thrombocytopenia, intracerebral hemorrhage, atherosclerosis, stent, and history of transient ischemic attack. R51's POS (Physician Order Sheet) shows an order dated 7/27/23 for aspirin tablet, chewable, 81 mg. 2. On 9/27/23 at 08:54 AM during medication pass, V12 was preparing and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-09-29 · tag F0813 — patternHave a policy regarding use and storage of foods brought to residents by family and other visitors.
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: label and date resident food, remove expired food items, complete temperature logs, and keep thermometers inside resident personal refrigerators. This applies to 11 of 11 residents (R29, R34, R35, R41, R43, R50, R51, R52, R80, R110, R112) reviewed for personal room refrigerators. The findings include: On 9/26/23 at 10:00 AM, initial tour was conducted on the first floor. The following observations were made: 1. At 10:36 AM, inside R51's fridge there was a can of whipped cream and 1 package of pudding. There was no temperature log on her fridge. 2. At 10:41 AM, R110's refrigerator had the June temperature log sheet in a plastic sleeve in front of refrigerator. It was missing temperatures for June 4th, 17-23, 26, 27, and 30th. There was no current log sheet for September 2023. 3. At 10:52 AM, inside R80's fridge there were 2 hydrolyte thickened waters, 2 old donuts in a plastic bag that were not labeled or dated, and a package of chocolate…
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 · D2023-09-29 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assist residents with eating their meals in a dignified manner. This applies to 2 of 2 residents (R50 and R66) reviewed for dignity in a sample of 32. The findings include: 1. R66's face sheet showed the following diagnoses of dementia, encounter for palliative care, lack of coordination and dysphagia. R66's Minimum Data Set (MDS) dated [DATE] showed that R66 needs supervision with one person physical assist with eating. R66's care plan (revised 8/29/23) for nutritional status shows that R66 has history of weight loss, is on hospice care, and needs assistance with meals. On 9/26/23 at 11:32 AM, during dining observation, V13 (CNA/Certified Nurse Aide) was observed standing beside R66 while feeding R66 lunch. On 9/27/23 at 1:05 PM, V13 said she assists R66 with meals because R66 cannot see and often misses her mouth when she eats. V13 said if there were seats available in the dining room, she would sit while feeding R66. V13 said she is 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 · D2023-09-29 · 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 ensure a resident's Physician Order Sheet concurred with a resident's most recent POLST (Practitioner Order for Life-Sustaining Treatment) form. This applies to 1 of 6 residents (R74) reviewed for advanced directives in a sample of 32. The findings include: R74's [DATE] POS (Physician Order Sheet) showed an order dated [DATE] for DNR (Do Not Resuscitate). R74's documents showed two POLST (Practitioner Order for Life-Sustaining Treatment) forms. R74 had a POLST form dated [DATE] for DNR and a POLST form dated [DATE] for full code. On [DATE] at 2:14 PM, V5 (RN/Registered Nurse) said she was the nurse taking care of R74. V5 said if R74 was in cardiac arrest, she would look in the binder on the crash cart. V5 also said she would look at the resident documents to see what the residents' code status was. V5 said she believed R74 was a full code and two weeks earlier; she had a conversation with him where he expressed being a full code. V5 checked R74's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-09-05 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure that hand soap is always available for hand washing. In addition, the facility also failed to follow standard infection control practices related to hand hygiene and gloving during provisions of wound care. This applies to 6 residents (R1, R3, R4, R5, R6, R7) reviewed for infection control in the sample of 7. The findings include: 1. On 8/24/23, there was an outbreak of Covid-19 in the memory care unit of the facility. The same day, from 9:23 AM through 11:15 AM, an environmental round was conducted to observe for availability of infection control supplies (personal protective equipment, and hand soap) in the memory care unit. It was noted that R1's, R4's, R5's, R6's, and R7's bathroom had no hand soap. There was no hand soap in the unit (memory care) hallway's bathroom used by visitors and staff. On 8/24/23 at 11:05 AM, R1 removed her right sock and showed her right foot which had a wound dressing on the big toe. Afterwards, R1 went to the bathroom to wash her hands and stated there was no soap in 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 · D2023-09-05 · 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 provide a clean and comfortable environment. This applies to 2 of 5 residents (R1, R8) reviewed for clean and comfortable environment in the sample of 8. The findings include: On 8/24/23 at 11:05 AM and 8/28/23 at 1:11 PM, R1 was in her room. R1's bedroom floor was sticky. The surveyor's shoes made a sound with each step on the floor. On 09/5/23 at 10:27 AM, V14 (Nursing Aid) rendered care to R8. The bedroom floor was sticky with each step made, the surveyor could hear and feel the sound of the floor's stickiness. V14 also verbalized the same thing. The vinyl floor was also dirty, and it was stained with black/brown substances. On 09/5/23 at 10:41 AM, V15 (Housekeeper) confirmed that R1's and R8's bedroom floor were sticky and not clean. V15 added that he does clean the floor daily but R1's and R8's vinyl flooring needed to be stripped. Housekeeping Services Policy dated January 2021 shows: Policy: It is the policy of this facility to maintain a clean, order free, comfortable, and orderly environment in all…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2022-09-22 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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 there was sufficient staffing available to meet the needs and safety of the residents in the facility. This failure has the potential to affect all 110 residents residing in the facility. The findings include: 1. R354's face sheet provided by the facility on 9/22/22 showed she was admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD), chronic diastolic heart failure, and dependence on supplemental oxygen, unsteadiness on feet, localized edema, hypertensive heart disease, and pain in right shoulder. R354's September 2022 Physician order report showed, 9/8/20, spironolactone 25 mg, oral, once a day 08:00 AM; iron 325 mg, oral, daily 08:00 AM; loratadine 10 mg oral daily 08:00 AM; Lasix 40 mg oral daily 08:00 AM; aspirin 81 mg oral daily 08:00 AM; Tylenol extra strength 500 mg 2 tabs, oral, 08:00 AM; Vitamin D3 125 mcg oral 08:00 AM; Vitamin C 500 mg oral 08:00 AM On 9/20/22, at 11:39…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-09-22 · 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 the observation, interview, and record review the facility failed to ensure freezer temperatures were maintained below zero degrees Fahrenheit and failed to ensure expired food and water were discarded. This has the potential to affect all residents in the facility. The findings include: The CMS 672 form dated 9/21/22 shows 110 residents reside in the facility. 1. On 9/20/22 at 10:27 AM, the facility walk-in freezer showed a temperature of 24*F (degrees Fahrenheit). At 11:45 the temperature of the freezer was 12* F. On 9/21/22 at 1:35 PM, the walk-in freezer was checked with V16 (Dietary Manager). The temperature was at 14*F. Several loaves of bread, pancakes, and nutritional supplement cups were soft and mushy. V16 stated that the temperature is too high. It should be at 0 *F or lower. These foods are supposed to frozen solid. The facility's freezer temperature log was posted on the wall next to the freezer. The recording for 9/21/22 at 1:30 PM (5 minutes earlier) was 0*F. The log for the entire month of September also showed a temperature of exactly 0*F for every entry…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-09-22 · 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
Based on observation, interview, and record review, the facility failed to wear personal protective equipment (PPE) into a COVID positive residents (R99) room per Centers for Disease Control (CDC) guidelines and failed to perform hand hygiene to prevent the spread of COVID-19. These failures have a potential to affect all residents in the building. The findings include: The Resident Census and Condition Report dated 9/21/22 showed 110 residents residing in the building. R99's electronic face sheet printed on 9/22/22 showed R99 has a diagnosis of COVID-19. R99's nursing care plan dated 9/16/22 showed, Resident has a need for droplet and contact isolation related to positive COVID-19 test. Have adequate PPE available for staff and visitors, practice good handwashing, use principles of infection control and droplet precautions. R99's physicians orders dated 9/16/22 showed, Isolation type: Contact and Droplet isolation related to positive rapid COVID-19 test. On 9/21/22 at 1:15PM, a sign was posted at the nurse's station showing, All staff wear N95 mask and face shield. A red sign was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-09-22 · 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 Observation, Interview, and Record Review the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes enhancement of his or her quality of life for 1 of 1 (R21) residents reviewed for resident rights in the sample of 24. The findings include: R21's face sheet provided by the facility on 9/22/22 showed she was admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD), chronic diastolic heart failure, dependence on supplemental oxygen, unsteadiness on feet and pneumonia. R21's September 2022 Physician order report showed, 4/29/22, oxygen: 3L (liters) NC (nasal cannula), continuous. R21's facility assessment dated [DATE] showed she had moderate cognitive impairment (Brief Interview for Mental Status Score 10), and was on oxygen therapy. R21's Care Plan initiated on 4/05/22 showed, R21 enjoys pursuing independent leisure . exercise, active games, bingo . The same care plan showed an intervention that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-09-22 · 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 observation, interview, and record review, the facility failed to ensure a resident's privacy during wound care for 1 of 1 resident (R36) reviewed for privacy in the sample of 24. The findings include: R36's Physician's Order Report dated 8/21/22-9/21/22, showed treatment orders to his left medial ankle and right lateral foot. On 9/21/22 at 9:36 AM, V4 (Agency/ Wound Nurse) was performing dressing changes to R36's wounds on his left medial ankle and right lateral foot. V4 did not close R36's door to his room or pull the curtain in R36's room prior to or during the wound care. R36 resided in the first bed (closest to the door) in that room. At 10:15 AM, V4 said she should have closed R36's door or pulled the curtains to maintain R36's privacy during wound care. On 9/22/22 at 1:23 PM, V2 (Director of Nursing) said staff should close the resident's door and pull the curtain when providing wound care for the resident, to maintain privacy for the resident. The facility's undated policy titled Respecting Residents' Privacy, showed Even though many people go in and out 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 before2022-09-22 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to meet resident incontinent needs for one of one resident (R23) reviewed for activities of daily living in the sample of 24. The findings include: R23's face sheet printed 9/22/22 showed diagnoses including but not limited to cerebrovascular disease, leukemia, acute respiratory disease, cancer, and dementia. R23's facility assessment dated [DATE] showed moderate cognitive impairment and staff assistance required for walking, toilet use, hygiene, and dressing. The same assessment showed R23 is occasionally incontinent of urine and bowel. R23's risk for skin breakdown report dated 9/9/22 showed a high risk. On 9/22/22 at 10:44 AM, V5 (CNA-Certified Nurse Aide) stated she last checked R23 for incontinence about 30 minutes ago, just before going on break. V5 said R23 was just slightly wet so I didn't change her then. V5 rolled R23 onto her left side and the incontinence brief was visibly saturated with urine. R23's bed pad and linens underneath…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-09-22 · 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 observation, interview, and record review, the facility failed to perform dressing changes per physician's orders for one of one resident (R205) reviewed for non-pressure wounds in the sample of 24. The findings include: On 9/21/22 at 2:50 PM, this surveyor asked V13 (Licensed Practical Nurse-LPN) to go into R205's room with her to see where his pressure areas were located. R205 had bandages on both of his feet. Both bandages were dated 9/19/22. V13 verified the date of 9/19/22 on both dressings. On 9/22/22 at 8:45 AM, V14 (LPN) went with this surveyor into R205's room to check his dressings. The dressings on R205's left and right feet were both still dated 9/19/22. V14 verified the dates on R205's dressings were both 9/19/22. On 9/22/22 At 9:56 AM, V4 (Agency Wound Nurse) and this surveyor went into R205's room so she could do the dressing change to R205's bilateral feet. The date on the dressings on both of R205's feet now said 9/20/22. V4 was asked if this was the first time R205's dressings had been changed today and V4 said yes. V4 was informed that at 8:45 AM, 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 · D2022-09-22 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Observation, Interview, and Record Review the facility failed to ensure the resident received respiratory care and services that is in accordance with professional standards of practice for 1 of 1 (R21) resident reviewed for oxygen therapy in the sample of 24. The findings include: R21's face sheet provided by the facility on 9/22/22 showed she was admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD), chronic diastolic heart failure, dependence on supplemental oxygen, unsteadiness on feet and pneumonia. R21's September 2022 Physician order report showed, 4/29/22, oxygen: 3L (liters) NC (nasal cannula), continuous. R21's facility assessment dated [DATE] showed she had moderate cognitive impairment (Brief Interview for Mental Status Score 10) and was on oxygen therapy. R21's Care Plan initiated on 4/05/22 showed, R21 has a diagnosis of COPD, at risk for complications. The same care plan showed an intervention to administer oxygen as ordered. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-09-22 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to administer medications at ordered times. There were 21 opportunities with 4 errors resulting in a 19.04 % error rate. This applies to 1 of 5 residents (R55) observed in the medication pass. The findings include: R55's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include dementia with behavioral disturbance, major depressive disorder, adult failure to thrive, and hypertension. R55's physician order sheet for September 2022 showed, Advair Diskus 100-50 mcg (micrograms) per dose to be given every 12 hours at 8:00 AM and 8:00 PM . felodipine 10 mg daily at 8:00 AM . Risperdal 0.5 mg three times a day at 8:00 AM, 12:00 PM, and 4:00 PM . losartan 25 mg daily at 8:00 AM . On 9/21/22 at 9:31 AM, V6 (Licensed Practical Nurse - LPN) was passing medications to R55. V6 administered R55's Advair, felodipine, Risperdal and losartan at 9:31 AM (1.5 hours after the scheduled time) On 9/21/22 at 9:31 AM, V6 said, We have…
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 · B2024-08-08 · tag F0572 — patternGive residents a notice of rights, rules, services and charges.
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 residents residing in the facility both orally and in writing of their resident rights. This applies to 7 of 10 residents (R1, R17, R25, R34, R53, R75, R101) reviewed for resident rights in the sample of 25. The findings include: 1. R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE]. R1's MDS (Minimum Data Set) dated June 3, 2024, showed R1 was cognitively intact. 2. R17's EMR showed R17 was admitted to the facility on [DATE]. R17's MDS dated [DATE], showed R17 was cognitively intact. 3. R25's EMR showed R25 was admitted to the facility on [DATE]. R25's MDS dated [DATE], showed R25 was cognitively intact. 4. R34's EMR showed R34 was admitted to the facility on [DATE]. R34's MDS dated [DATE], showed R34 was cognitively intact. 5. R53's EMR showed R53 was admitted to the facility on [DATE]. R53's MDS dated [DATE], showed R53 was cognitively intact. 6. R75's EMR showed R75 was admitted to the facility on [DATE].…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
$75,389 in federal fines across 3 penalties. 1 Medicare payment denial on record.
- $17,215 — penalty dated 2026-04-27
- $47,655 — penalty dated 2025-07-30
- $10,519 — penalty dated 2025-03-13
- Medicare payment denial — starting 2025-08-23 for 17 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to EXTENDED CARE CLINICAL — 9 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.2 | -0.2 vs chain |
| Health inspection | 3 of 5 | 2.7 | +0.3 vs chain |
| Staffing | 1 of 5 | 1.1 | -0.1 vs chain |
| Quality measures | 2 of 5 | 3.6 | -1.6 vs chain |
The other 8 homes this chain runs (chain average 2.2★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| ROTHNER HEALTH VENTURES G II, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 01/01/2013 |
| ARONIN, DAVID | Individual | CORPORATE DIRECTOR | — | since 06/06/1989 |
| ISRAEL, LEVI | Individual | CORPORATE OFFICER | — | since 01/01/2023 |
| KAMRAN, UROOSA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2023 |
| KANTER, SHIMON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/18/2023 |
| ADAMS VALES ACCUMULATION TRUST | Organization | TRUSTEE OF THE SNF; ADP OF THE SNF | — | since 01/01/2015 |
| DANIEL ROTHNER ACCUMULATION TRUST | Organization | TRUSTEE OF THE SNF; ADP OF THE SNF | — | since 01/01/2015 |
| KATHRYN VALES ACCUMULATION TRUST | Organization | TRUSTEE OF THE SNF; ADP OF THE SNF | — | since 01/01/2015 |
| KIMBERLY VALES ACCUMULATION TRUST | Organization | TRUSTEE OF THE SNF; ADP OF THE SNF | — | since 01/01/2015 |
| MELISSA ROTHNER ACCUMULATION TRUST | Organization | TRUSTEE OF THE SNF; ADP OF THE SNF | — | since 01/01/2015 |
| NATHAN AND SHIRLEY ROTHNER FAMILY TRUST | Organization | TRUSTEE OF THE SNF; ADP OF THE SNF | — | since 01/01/2015 |
| RACHEL ROTHNER ACCUMULATION TRUST | Organization | TRUSTEE OF THE SNF; ADP OF THE SNF | — | since 01/01/2015 |
| WILLIAM ROTHNER ACCUMULATION TRUST | Organization | TRUSTEE OF THE SNF; ADP OF THE SNF | — | since 01/01/2015 |
| AROUND THE CLOCK HEALTHCARE SERVICES, INC. | Organization | ADP OF THE SNF | — | since 01/01/2023 |
| EXTENDED CARE CLINICAL LLC | Organization | ADP OF THE SNF | — | since 01/01/2015 |
| EXTENDED CARE CONSULTING LLC | Organization | ADP OF THE SNF | — | since 01/01/2015 |
| KARE TECHNOLOGIES LLC | Organization | ADP OF THE SNF | — | since 01/01/2023 |
| ROTH & CO, LLP | Organization | ADP OF THE SNF | — | since 01/08/2025 |
CMS files one row per role, so the 29 rows in the source record cover these 18 parties — each is shown once here with every role it holds. Nothing is omitted.
14 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.
About 77% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.8M paid to related parties — landlords or management companies under common ownership — equal to about 13% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145614. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-08-08, 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.