1010 West 95th Street, Chicago, IL 60643 · Cook County · (773) 298-1177
228 certified beds, about 176 residents a day · For profit - Corporation · Medicare and Medicaid since 1996
CMS Care Compare ratings, data as of September 1, 2026 · CCN 145914 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on July 24, 2025, inspectors cited 12 health deficiencies (the Illinois average is 12.6, the national average 9.2).
Of 101 health citations since June 2023, 12 were rated as actual harm or immediate jeopardy to residents (1 immediate jeopardy).
CMS lists 7 fines totaling $595,647 in the last three years; the largest was $195,940, and the latest is dated June 16, 2026.
Nurses and nurse aides worked 2.61 hours per resident per day, against 3.45 across Illinois and 3.86 nationally. Registered nurses accounted for 0.16 of those hours.
40.8% of nursing staff left within the year CMS measured (Illinois average 44.5%).
CMS links it to Infinity Healthcare Consulting, an affiliated group of 70 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 101 health citations on file.
Inspectors wroteBased on interview and record review the facility failed to protect one resident (R2) out of four residents who were reviewed for abuse and the facility failed to report a suspicion of abuse and/or unknown injury to the abuse coordinator. Subsequently the resident sustained multiple bruises and trauma. Findings Include:R2's Progress note dated 06/03/26 19:48 document in part reads: Nursing Progress Note Text: Resident observed with discoloration to the forehead and discoloration to the right side of his face. Further skin assessment revealed discoloration to the right hip area. Attending physician notified and gave orders to send resident to hospital for evaluation. On 06/17/26 at 03:05 PM V21 (Certified Nurse Assistant) stated I did not witness R2 and R24 altercation. After the fact, I prepped R2 to go to the hospital. [...]
Inspectors wroteBased on interview and record review the facility to seek medical attention right away for one resident (R2) who was on anti-coagulant medications after the resident told the nurse he was in an incident with another resident and an injury was noted to his face. Subsequently the resident was not sent to the hospital until a day later after a mark was noted and where resident required hospitalization for a Intracranial Hemorrhage and Hematomas to other parts of his body. [...]
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide effective pest control for six [R1, R4, R15, R16, R22, R23] residents in the sample of 25. These failures have the potential to affect all 157 residents residing in the facility. Findings Include, R1's clinical record indicates the following in part: R1's medical diagnosis of schizoaffective disorder, depression, anxiety disorder, movement disorder, type II diabetes, chronic obstructive pulmonary disease, essential hypertension, liver disease, morbid obesity, transient ischemic attack and cerebral infarction, chronic kidney disease, edema, and chronic pain. [...]
Inspectors wroteF761Based on observation, interview, and record review, the facility failed to properly store medications requiring refrigeration for four residents (R7, R8, R9, and R10). This failure has the potential to affect all four residents reviewed for physical environment and medication storage.
Inspectors wroteBased on interviews and record review, that facility failed to ensure that one resident (R1) was free from verbal abuse by a staff member. This failure has affected one (R1) resident from a sample of nine residents reviewed for abuse.
Inspectors wroteBased on observation, interview and record review the facility failed to provide wound care treatments for two residents R1 and R5, failed to notify the physician when wound worsened for one resident (R1) resulting in R1 being sent to the hospital for wound infection and needing further surgical interventions, failed to assess and treat wounds for one resident (R5) resulting in R5 not receiving wound care for 12 days. These failures affected two residents (R1 and R5) out of 3 residents reviewed for wound care.
Inspectors wroteBased on observations, interviews and records reviewed the facility failed to ensure medications were securly stored, in accordance with professional standards and not left at the bedside of a visually impaired resident, (R4). This failure has the potential to affected of 1 of 3 residents reviewed for quality of care.
Inspectors wroteBased on observation, interview and record review, the facility failed to wear PPE (Personal Protective Equipment) for one resident (R1) who is on EBP (Enhanced Barrier Precautions) while providing wound care. The facility failed to identify one resident requiring EBP with an indwelling catheter and pressure ulcer. This failure affected two residents (R1 and R4) out of three residents reviewed for infection control.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe and sanitary functional environment (the second-floor unit soiled utility room). This failure has the potential to affect all 72 residents residing on the second floor unit.
Inspectors wroteBased on interview and record review, the facility failed to ensure that residents wear appropriate footwear to prevent falls, for one of three residents reviewed for falls (R3) in the sample of 18. This failure resulted in R3 falling and sustaining a subarachnoid hemorrhage and subdural hematoma.
Inspectors wroteBased upon interview and record review, the facility failed to report an injury of unknown origin to the state surveying agency within regulatory requirements for one (R7) resident. This failure has the potential to affect all 172 residents residing in the facility.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain laundry equipment in good working conditions that provides laundry services to all residents. These failures have the potential to affect all 172 residents living in the facility receiving laundry services.
Inspectors wroteBased on interview and record review, the facility failed to implement a portion of an existing plan related to pressure ulcer care, such as not following treatment/dressing changes as ordered for one (R3) resident out of four reviewed for pressure ulcers in a total sample of 17 residents. However, there has been no evidence of decline or failure to heal. This failure places the resident at risk for more than minimal harm.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and monitoring for three (R15, R16) residents in a total sample of 17 residents reviewed.
Inspectors wroteBased on interviews and record reviews, the facility failed to provide sufficient staffing to ensure ADL (Activities of Daily Living) needs are met in a timely manner for two residents (R4, R8) and medications are being administered as ordered by the physician. The facility's short staffing has the potential to affect all residents residing on the first floor of the facility.
Inspectors wroteBased on interview and record review, the facility failed to ensure that call lights were answered in a timely manner for one (R1) out of three residents reviewed for accommodation of needs. Findings Include:R1's face sheet listed diagnoses, but not limited to, orthostatic hypotension, end staged renal disease, and polyosteoarthritis. R1's Minimum Data Set (MDS) assessment dated [DATE] shows R1 is cognitively intact with BIMS (Brief Interview for Mental Status) score of 15. On 1/25/26 at 9:57 AM, R1 was sitting up in bed alert and oriented to person, place, and time. Able to verbalize needs with no difficulty. R1 stated that his call light was on for more than two hours on 1/21/26 around 4:20 PM to get his urinal emptied and get water to drink. R1 said nobody answered his call light until 6:45 PM. R1 said he called the reception four times to send someone, and nobody came. [...]
Inspectors wroteBased on observation, interview and record review the facility failed to ensure medications were administered as scheduled per physician orders for two (R1, R4) out of three residents reviewed for medication administration. Findings Include:On 1/25/26 at 9:57 AM, R1 was sitting up in bed alert and oriented to person, place, and time. Able to verbalize needs with no difficulty. R1 stated that he did not receive his scheduled morning medications at 6:00 AM today and received it at 8:00 AM instead. R1 also stated that on 1/21/26, he did not receive his scheduled Eliquis, Multivitamin, and Midodrine.1/25/26 at 2:14 PM, a phone interview was conducted with V18 (Registered Nurse) and stated he was R1's nurse on 1/21/26 night shift until 1/22/26 and leaves at 7:30 AM. V18 denied giving R1's Midodrine late on 1/21/26. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure (a) signage for Enhanced Barrier Precautions (EBP) was posted and (b) staff / visitor wear proper personal protective equipment (PPE) for resident on contact precautions. These failures affected two (R1 and R3) out of four residents reviewed for Infection Control.
Inspectors wroteBased on observations, interviews and review of records the facility failed to protect the right of every resident to privacy and dignity by failing to place privacy shower curtain in the shower room for 31 residents using shower room and failed to ensure resident maintain their privacy during shower for 1 out of 4 residents (R3) reviewed for resident rights. These failures have the potential to affect all 31 residents using shower room without privacy curtain and affected 1 resident (R3) who felt exposed during shower.
Inspectors wroteBased on observations, interviews and review or records the facility failed to maintain complete and accurate resident record for 1 out of 4 residents (R3). These failures affected 1 resident (R3) who felt exposed during shower without documentation as to interventions done to address concerns.
Inspectors wroteBased on interviews and record review, the facility has failed to ensure that all residents are aware of the grievance process and that resident's concerns are addressed in a timely manner. This failure has affected two residents (R132 and R143) and has the potential to affect 146 additional residents that reside in the facility.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility's menu to meet nutritional needs of residents which has the potential to affect the 145 residents receiving oral diets in the facility.
Inspectors wroteBased on observation, interview, and record review the facility failed to store foods at safe temperatures, Label foods with expiration dates, and document freezer and walk-in cooler temperatures on the tracking logs. This failure has the potential to affect 143 residents on oral diets out of 148 residents in the facility. Facility [NAME], [NAME] (51772) - Kitchen
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff don appropriate PPE (personal protective equipment) prior to performing ADL (Activities of Daily Living) care and prior to administering medications via a g-tube for residents on EBP (enhanced barrier precaution). The facility also failed to ensure soiled linens were contained in plastic bag and tied when transported via laundry chute to prevent the spread of infectious microorganisms. These failures affected 2 (R21 and R102) residents reviewed for infection control and have the potential to affect all 148 residents at the facility.
Inspectors wroteBased on interview and record review the facility failed to refer seven residents R1, R5,R6,R7,R12, and R88 to the appropriate state designated authority for a Level II PASARR (Preadmission Screening and Annual Resident Review) evaluation and determination after R1,R5,R6,R7,R12,and R88 were all diagnosed with a new mental disorder. This deficient practice affected seven residents (R1, R5, R6,R7,R12,R44and R88) in a total sample size of 64 residents.
Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that one resident (R45) did not have razors at her bedside; the facility failed to ensure that one resident (R12) did not have a filled sharps container on his bedroom floor; and the facility failed to ensure that five residents (R43, R49, R68, R69, and R105) did not have an overfilled sharps container in their room. This failure has the potential to affect 117 Residents that reside on the second and third floor of the facility.
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to discard expired stock medications in two of five medication carts, and failed to ensure the medication refrigerator was checked for appropriate temperature log recordings. These failures affected 3 (R32, R76, and R123) residents and has the potential to affect all residents on the first and third floor.
Inspectors wroteBased on interview and record review, the facility failed to follow the physician's order to conduct a gradual dose reduction(GDR) evaluation as required by the gradual dose reduction order recommendations for unnecessary medication, chemical restraints/psychotropic meds, and medication record review, and discontinue a psychotropic medication for a resident who has a recommendation to discontinue a psychiatric diagnosis. This failure affected 2 residents (R7 and R12) in a sample size of 64.
Inspectors wroteBased on interview and record review the facility failed to refer one resident (R105) for rescreening to the state agency for Preadmission Screening and Resident Review (PASRR) before R105's Exempted Hospital Discharge 30 Day Approval expired and failed to complete a Level I Preadmission Screening and Resident Review (PASRR) for one residents ( R12) This deficient practice affected two residents (R105,R12) in a total sample size of 64 residents.
Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that one resident (R118's) with decreased mobility had a properly working Low Air Loss Mattress. This failure resulted in R118 lying on a deflated mattress and verbalizing being uncomfortable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nasal cannula was labeled with the date it was changed. This failure affected 1 (R121) resident reviewed for respiratory care in the total sample of 64 residents.
Inspectors wroteBased on observation, interview, and record review the facility failed to label, date, and discard food items in resident 's personal refrigerator in an effort to prevent food borne illness. This failure affected 1 (R36) resident reviewed for personal refrigerator in the total sample of 64 residents.
Inspectors wroteBased on observations and interviews, the facility failed to provide a homelike environment by ensuring that there were no visible holes in the ceilings of two shower rooms. This failure has effected one resident (R10), and has the potential to affect 117 residents who utilize these shower rooms.
Inspectors wroteBased on observation, interviews and records review the facility failed to follow their policy to ensure one (R2) resident remained free from physical abuse by another resident (R1) in a sample of four reviewed. This failure resulted in R1 hitting R2 with a bottle causing an open wound over R2's left eyebrow.
Inspectors wroteBased on interview and record review, the facility failed to prevent and protect one resident (R1) from resident-to-resident abuse out of four residents reviewed for physical assault. This failure resulted in R1 sustaining a fracture of the left ankle in a total sample of four residents.
Inspectors wroteBased upon interview and record review the facility failed to follow the abuse prevention program, failed to provide supervision, failed to implement preventive interventions, and failed to ensure that two of seven residents (R1, R2) in the sample remained free from abuse. These failures resulted in (8/9/24) physical altercation between R1 and R2. R1 sustained a displaced fracture of the left 5th metacarpal, right shoulder deformity and right eye discoloration. R2 sustained a scratched forehead.
Inspectors wroteBased upon observation, interview, and record review the facility failed to follow policy procedures and failed to ensure that call lights were within reach for three of three residents (R3, R4, R7) reviewed for falls.
Inspectors wroteBased upon record review and interview the facility failed to timely notify the Physician, Nurse Practitioner, and/or Medical Director of change in condition for one of three residents (R4) reviewed for falls.
Inspectors wroteBased upon record review and interview the facility failed to follow policy procedures and failed to timely develop comprehensive care plans for two of seven residents (R4, R6) in the sample.
Inspectors wroteBased upon record review and interview the facility failed to follow policy procedures and failed to review and/or revise a comprehensive care plan for two of three residents (R3, R7) reviewed for falls.
Inspectors wroteBased upon observation, interview, and record review the facility failed to follow policy procedures, failed to provide supervision, failed to ensure that staff are aware of required fall prevention interventions, and/or failed to implement fall prevention interventions for three of three residents (R3, R4, R7) reviewed for falls.
Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure to prevent R1 from being physically abused by R2. This failure affected 1 (R1) of 4 residents reviewed for abuse.
Inspectors wroteBased on interview and record review, the facility failed to follow their policy & procedure to prevent R2 from being physically abused by R1. This failure affected 1 (R2) resident out of 4 residents reviewed for abuse.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered as ordered by the residents' physician for one (R5) resident out of three residents reviewed.
Inspectors wroteBased upon record review and interview the facility failed to ensure that staff are aware of facility policies, failed to follow policy procedures, and failed to develop a comprehensive care plan including required interventions for three of three dependent residents (R1, R2, R3) in the sample. These failures have the potential to affect 145 residents.
Inspectors wroteBased upon observation, interview, and record review the facility failed to ensure they have a written staffing policy, failed to ensure that the required amount of staff are scheduled, failed to ensure that scheduled staff arrive timely and/or stay for the entire shift, and failed to ensure that sufficient nursing staff were available to meet the needs for three of three dependent residents (R1, R2, R3) in the sample. These failures have the potential to affect 145 residents.
Inspectors wroteBased upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure the building is well maintained, failed to ensure that facility repairs are documented, failed to timely identify an area needing repair, failed to address falling ceiling tiles, and failed to timely repair a malfunctioning actuator. The facility also failed to pay the HVAC (Heating Ventilation Air Conditioning) company. These failures have the potential to affect 145 residents.
Inspectors wroteBased upon observation, interview, and record review the facility failed to ensure that staff report hazards and/or housekeeping concerns, failed to ensure that resident rooms are clean and hazard free, failed to ensure that spills are addressed immediately, and failed to ensure that dining rooms are cleaned timely. These failures have the potential to affect 82 residents residing on 1st and 3rd floor.
Inspectors wroteBased upon record review and interview the facility failed to follow policy procedures, failed to ensure that care plans include discharge planning on admission, failed to ensure the discharge care plan includes actual discharge plan, failed to follow-up on transfer referral(s), and failed to transfer one of three residents (R1) reviewed for discharge timely.
Inspectors wroteBased upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that care plans include required assistance, and failed to provide timely ADL (Activities of Daily Living) care to two of three dependent residents (R1, R3) in the sample.
Inspectors wroteBased on interviews and record reviews the facility [ A] failed to monitor and recognize change in condition for one resident [R3]out of 4 residents with known history of chronic kidney disease fluid volume status, [B] failed review and address diagnostic test results, and [C] failed to follow physician orders to schedule nephrology, cardiology, and pulmonary consultant appointments. These failures resulted in R3 being sent to the emergency department very weak, massive volume overload, worsening kidney function, pulmonary edema, respiratory failure, hypotension, and diagnosed with cardiorenal syndrome, in acute renal failure, admitted to intensive care unit to place line for emergent dialysis. The facility's immediate jeopardy began on [DATE]. On [DATE] at 2:25 PM, the administrator was notified of the immediate jeopardy. The immediate jeopardy was removed on [DATE] at 1:59 PM. [...]
Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide ADL (Activity of Daily Living) care to residents who are dependent on staff assistance with ADL's. This failure affected 3 [R2, R3, R4] of three residents reviewed for incontinence care and personal hygiene. This failure resulted in R2 feeling the urine and feces burning in R2's wound, R3 feeling itching and burning due to delayed care and R4 not receiving incontinence care for 12 hours and which resulted in R4 itching and scratching all night from urine. Findings Include, R2's clinical record indicates in part; R2's medical diagnosis was muscle wasting, paraplegia, and major depressive disorder. Minimum Data set [MDS] Section [C] dated 8/6/24, Brief interview mental status scored [15], indicates R2 is cognitively intact. [...]
Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their skin condition assessment policy to ensure three [R1, R2, R3] of three residents wound dressings were checked for placement, and cleanliness, and failed to complete wound care as prescribed for one [R1] resident. These failures resulted in R1 developing a stage II pressure wound on his left rear thigh, R2's wound increased in size, and R3 developed moisture associated dermatitis. Findings Include, R1's clinical record indicates in part; R1 was admitted with the medical diagnosis of heart failure, chronic obstructive pulmonary disease, schizoaffective disorder, reduced mobility, abnormal gait and mobility, lack of coordination, acquired absence of left leg below knee, and muscle weakness. R1's Minimum Data Set, dated [DATE], R1 is cognitively intact [scored 15], alert and oriented x3. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide bed linen and bath towels for four (R1, R2, R3, R4) out of four residents and failed to ensure the facility's washing machines was functioning properly. This failure has the potential to affect all 150 residents residing in the facility. Findings Include, On 9/10/24 at 10:00 AM, R1 stated, I never have clean face towels to clean myself up in the morning. The nurses tell me I have to wait for the clean laundry to come up, sometimes the laundry does not come up until 1 PM. I should not have to take my own money to buy face towels. R2's clinical record indicates in part; R2's medical diagnosis was muscle wasting, paraplegia, and major depressive disorder. Minimum Data set [MDS] Section [C] dated 8/6/24, Brief interview mental status scored [15], indicates R2 is cognitively intact. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure waste containers were properly contained and covered. This failure has the potential to affect all 156 residents residing in the facility.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident obtained/consumed alcohol, failed to ensure alcoholic beverages and razors were stored in a safe manner. This failure effected 2 residents (R149 and R410) and has the potential to affect all 67 residents on the second floor and 31 residents on the first floor of the facility.
Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure oxygen tubing, humidifier bottle, and nebulizer mask were dated, failed to ensure that a resident receiving oxygen have oxygen orders, and failed to ensure respiratory equipment (incentive spirometer, peak flow meter, and nebulizer mask) were contained. These failures affected 4 residents (R49, R59, R360 and R410) reviewed for oxygen in a sample size of 71.
Inspectors wroteBased on observation, interview and record review, the facility failed to post the daily nursing staffing. This failure has the potential to affect all 156 residents residing in the facility.
Inspectors wroteOn 07/14/24 at 10:31 AM, R113 was cleaning up her (R113) personal refrigerator. This surveyor requested to see what was inside R113's refrigerator. R113 opened her (R113) personal refrigerator and stated I (R113) have different kind of food, (pointing to each food) R113 stated I (R113) cottage cheese, yogurt, egg salad, and avocado; food that regular people eat. I (R113) buy my (R113) own food. This surveyor requested to see R113's temperature log. R113 stated it is on the side. R113's (07/2024) personal refrigerator temperature log has no entry from 07/02/2024 through 07/13/2024. On 07/14/24 at 10:34 AM, V12 (Housekeeping Aide) stated the Guardian Angels are in charge of checking the personal refrigerator temperature. [...]
Inspectors wroteBased on observation, interview and record review the facility failed to perform hand hygiene before performing direct care to resident; failed to perform hand hygiene in between assisting residents during dining service; and facility failed to post an Enhanced Barrier Precautions (EBP) isolation sign and place Personal Protective Equipment (PPE) directly outside a resident's isolation room in an effort to prevent the spread of infectious microorganisms. These failures affected R36, R42, R79, and R120 in the sample of 71 residents and has the potential to affect all 89 residents residing on 1st and 3rd floors when reviewed for infection control.
Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a resident's dignity by covering a resident's indwelling catheter urinary bag from public view and failed to maintain a resident's dignity during one-to-one feeding by a staff member by sitting eye level with the resident and engaging with only one resident during one-to-one feeding. These failures affected R2 and R36 in the total sample of 71 residents when reviewed for resident rights.
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure call devices were within residents' reach for use to call for staff assistance. This failure affected 3 residents (R18,R41 and R155) reviewed for accommodation of needs in a total sample of 71 residents.
Inspectors wroteBased on interview and record review the facility failed to follow a resident's care plan for assessed resident's to exercise their right to engage in an intimate sexual relationship. This failure affected 2 residents R8 and R65 in a total sample of 70.
Inspectors wroteBased on observation, interview, and record review the facility failed to list the code status for one resident (R133) on the electronic medical record. This failure has the potential to affect one resident (R133) out of a sample of 71 residents.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide nail care for two residents (R18, R41). This failure affected two residents (R18, R41) and has the potential to affect all residents in the sample of 71 residents.
Inspectors wroteBased on observation, interview, and record review the facility failed to apply a hand splint to a resident with contracture, failed to ensure a hand splint was applied on correct hand, and failed to ensure the resident was appropriately care planned for a hand splint in an effort to prevent further contracture of the hand and functional decline of the resident. These failures affected 1 (R83) resident reviewed for limited range of motion in a total sample of 71 residents.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure incoming and outgoing nurses counted the controlled medications during shift change; and failed to ensure administration of controlled medication was documented. These failures affected three residents (R53, R62 and R87) reviewed for pharmacy services and records in a total sample of 71 residents.
Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure washcloths were changed in between dirty body surface areas, failed to ensure a sign is posted for a resident on enhanced barrier precautions and failed to ensure staff appropriately don and doff personal protective equipment during high contact care for a resident on enhanced barrier precautions in an effort to prevent the spread on Multidrug Resistant Organism. This failure affected 1 (R3) resident reviewed for infection control and has the potential to affect all the residents on the first floor.
Inspectors wroteBased interview and record review, the facility failed to develop a plan of care for Foley catheter use. This failure affects 1 resident (R4) sampled for Foley catheter care.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician orders are in place for residents utilizing Foley catheters and provide care for residents with Foley catheters. This failure affects 1 resident (R4) sampled for Foley catheter care.
Inspectors wroteBased on interview and record review, the facility failed to provide as needed medication for pain prior resulting with one resident suffering from excruciating pain and refusing to be touched during therapy and restorative sessions. This failure affected 1 (R3) resident reviewed for pain management in the total sample of 11 residents.
Inspectors wroteBased on observation, interview and record review facility failed to follow professional standards of practice and facility policy to (a) ensure incontinence care were provided timely for two residents (R4, R6), and (b) to ensure provider orders were followed in preventing alterations in skin integrity for one resident (R4). These failures have the potential to affect 2 (R4, R6) out of 3 residents reviewed for skin preventive measures. Findings Include: On 5/7/2024 at 9:55 AM V10 (Certified Nursing Assistant/CNA) entered and then exited R4's room and stated R4 is normally wet so I need to get her up and get her cleaned up before she eats. On 5/7/2025 at 10:07 AM V10 (CNA) started to get R4 to a sitting position in bed and diaper observed by surveyor to appear wet. Surveyor asked if R4 was wet or soiled. V10 (CNA) stated Yeah, just a little bit. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed accurately assess and supervise one resident's (R4) out of three residents reviewed for falls.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure and failed to follow a resident's care plan to ensure a resident received the correct oxygen flow rate as ordered by the physician for 1 (R3) out of 3 residents receiving supplemental oxygen. Findings Include: R3's clinical records show R3 was admitted in the facility on 3/29/24 with diagnoses not limited to Chronic Obstructive Pulmonary Disease (COPD) and Hypoxemia. R3's Minimum Data Set (MDS) dated [DATE] shows R3 is cognitively intact. R3's order summary report with active orders as of 5/7/24 reads in part: Oxygen @ 2 Liters/Min via nasal cannula continuous every day and night shift for COPD ordered on 4/23/24. R3's care plan shows R3 has Oxygen Therapy related to insufficient gas exchange with one intervention that reads: OXYGEN SETTINGS: [...]
Inspectors wroteBased on interviews, and record reviews the facility failed to ensure one [R1] of three sampled residents was free of verbal abuse from an employee. R1's clinical record documented in part: R1 was admitted on [DATE] with the following medical diagnosis of abnormalities of gait and mobility, pulmonary embolism, heart failure, anemia, type ll diabetic, acute embolism of deep veins of lower extremity, ulcer of right/left lower leg, muscle weakness, and essential hypertension. R1's Minimum Data Set Brief Interview for Mental Illness indicated R1 was cognitively intact. R1's care plane dated 1/21/24 documents in part: -R1 assessment reveals a history of suspected abuse and neglect or other factors that may increase my susceptibility to abuse and neglect. -R1 has a self-care deficit with impaired transfer abilities due to general weakness. -R1 has impaired coordination, gait, and balance. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to assess/monitor one resident (R1) for self-administration of medication out of three residents reviewed for medication administration.
Inspectors wroteBased on interview and record review, facility failed to affirm the right of the resident to be free from verbal abuse. This deficient practice affected two (R3, R5) out of three residents reviewed for abuse. Findings Include: On 01/30/2024 at 10:37AM, R3 observed lying in bed with a gown on inside of R3's room. R3 states approximately around thanksgiving time, she pulled her called light because R3 needed staff to assist R3 with having her incontinence briefs changed. R3 states V9 (Former Certified Nursing Assistant/CNA) came into R3's room and yelled What do you want? R3 states after she told V9 her reason for pulling the call light, V9 stated I'm going to change you so you can't let the men staff play with your p***y, because that's all you want anyway. R3 states V9 then told R3 that V9 was not going to change R3's incontinence briefs and V9 left R3's room. [...]
Inspectors wroteBased on interview and record review, the facility failed to report and investigate verbal abuse for one (R5) of three residents reviewed for abuse.
Inspectors wroteBased on interview and record review, the facility failed to prevent a fall by not implementing effective fall interventions for residents (R5, R6) who were at risk for fall and with history of falling and failed to supervise (R16) from smoking while oxygen is in use. The facility failed to ensure that resident (R7) was assessed by nurse before moving / transferring back to bed, facility failed to follow facility policy and procedutes and failied to follow residents care plans. These failures resulted in (R5) sustaining an lumbar compression fracture, (R6) sustaining acute subdural hematoma. These failures affected 4 (R5, R6, R7,R16) out of 4 residents reviewed for resident safety / falls/supervision.
Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate the needs of one (R1) resident by failing to ensure call light was within reach for R1 to use it if desired, in a sample of three residents reviewed.
Inspectors wroteBased on interview and record review, the facility failed to ensure resident to resident physical abuse did not occur for two of three residents (R12, R13) reviewed for abuse.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide sufficient staffing to ensure ADL (Activities of Daily Living) care was provided for dependent residents who required assistance with bladder and bowel incontinence for one(R1) of three residents reviewed for ADL care.
Inspectors wroteBased on observation, interview and record review the facility failed to follow their policy to identify residents at risk for impaired nutritional status, adjust nutritional interventions and notify the family of persistent decline in appetite and food intake. This failure affected 1 resident (R8) of 3 residents reviewed for nutrition.
Inspectors wroteBased on observations and interviews, the facility failed to provide sufficient staffing to ensure ADL (Activities of Daily Living) care was provided for dependent residents who required assistance with bladder and bowel incontinence for one of three residents (R1) reviewed for ADL care.
Inspectors wroteBased on record review and interview the facility failed to protect residents from being abused and failed to immediately intervene in situations before residents became physically aggressive towards their peers for four (4) of six (6) residents (R4, R5, R6, R7) reviewed abuse. Findings Include: Facility's abuse report dated 8/27/23 denotes brief description of Incident: Facility received report that R4 and R5 were involved in an unwitnessed peer to peer incident. R4 was interviewed and stated R5 came into his room and was going through his belongings. R4 was yelling for her to leave his room and a staff member then escorted R5 from his room. R4 appeared agitated and was sent out for behavior per physician order. R4's 8/23/2023 15:09 Social Service Note Text reads: Behavior Note: Per staff's report, resident was inappropriate towards staff. [...]
Inspectors wroteBased on interviews and record reviews, the facility failed to protect R110's right to be free from physical abuse by a resident. This failure resulted in R132 hitting R110 on the face. R110 was sent to acute hospital and showed R110 sustained a nasal fracture and dental injury. Findings Include: On 6/06/23 at 11:22 AM, an interview conducted with R110. R110 stated that another resident (R132) who's room was right across R110's room had hit R110 on the face. R110 stated that R132 came in R110's room, woke R110 and started hitting R110. R110 stated, The resident hit me on my nose bridge and my mouth. It was another resident. His name was [R132] he was right next door across the hall. It was around 2 o'clock in the morning. I don't remember the exact date. It was last week Tuesday. I was sleeping he was waking me up then he hit me on the face. [...]
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to: Maintain shift change accountability records for controlled substances that enables periodic reconciliation and accounting for residents'controlled medications and failed to ensure that controlled medications are placed into a secured storage area and double locked. These failures have the potential to affect all 180 residents residing in the facility as of census dated 6/6/23.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow policy and procedures for medication storage and labeling to: Discard expired house-stock medications and supplements as well as an expired resident-specific medication for one resident (R20). Discard expired medications from the convenience box inside the refrigerator. Ensure personal food items were not stored in medication carts. Ensure that food is not stored in the refrigerator where medications are stored. Ensure that medications are stored in an orderly manner in refrigerator of sufficient size to prevent crowding. Label a multi-dose insulin pen and inhalers with an open date for four residents (R18, R27, R45, R84). [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a.) food items were properly labeled, dated, and stored, b.) proper use of hair restraints worn by staff, c.) hand washing policy followed, d.) cook/service ware sanitized according to manufacturer guidelines. These deficient practices have the potential to affect all 173 residents receiving food prepared in the facility's kitchen.
Inspectors wroteBased on interviews and record reviews, the facility failed to provide a policy for COVID-19 Immunization for staff and residents and failed to provide documentation for two residents (R59, R80) who declined the vaccine. This has the potential to affect all180 residents that reside in the facility.
Inspectors wroteBased on interview and record review, the facility failed to properly assess and provide specific services needed based on diagnosis when failing to initiate a level II Pre-admission Screening and Resident Review (PASARR) for 7 (R2, R3, R59, R78, R81, R82, R94) residents reviewed for PASARR in a sample of 35.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that wound dressing was in place for one (R25) resident and maintain appropriate setting for low air loss mattress for three (R2, R35, R124) residents. These failures have the potential to affect four (R2, R25, R35, R124) of five residents reviewed for pressure ulcer in a sample of 35.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their 'Oxygen Administration' policy by not labeling oxygen equipment and replacing oxygen tubing, humidifier bottles and nebulizer equipment weekly and failed to follow infection control measures to properly store oxygen tubing when not in use. This affected 4 (R93, R110, R111, R181) out of a total sample of 35 residents.
Inspectors wroteBased on observation, interview, and record review the facility failed follow pureed menu and recipes and failed to give adequate portion sizes of pureed food to 11 residents (R2, R25, R35, R36, R74, R78, R79, R97, R101, R159 and R241) out of 8 residents reviewed for menus and nutritional adequacy in a sample of 35.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to contain and transport soiled linen in a manner that prevents or limits the spread of infection and don personal protective equipment (PPE) during patient care for a resident (R125). This has the potential to affect all 48 residents that reside on the first floor.
Inspectors wroteBased on interview and record reviews, the facility failed to provide eligible residents and/or resident representatives education regarding the benefits and potential side effects of all available pneumococcal and influenza vaccinations and assess eligibility and offer pneumococcal vaccinations to five (R38, R37, R52, R59, and R80) of five residents reviewed for pneumococcal and influenza vaccinations. Findings Include: 1. Review of R38's electronic medical record (EMR) revealed R38 was admitted to the facility on [DATE] and is [AGE] years of age with diagnoses that included but were not limited to: stage 3 chronic kidney disease, anemia, and heart failure. Review of R38's current physician orders with active orders as of 6/8/23 revealed R38 had no orders to receive pneumococcal and influenza vaccinations. [...]
Inspectors wroteFACILITY Based on interview and record review, the facility failed to complete the quarterly Minimum Data Set (MDS) assessment using the CMS-specified Resident Assessment Instrument (RAI) process within the regulatory timeframe for 1 (R149) of 1 resident reviewed for quarterly resident assessment in a sample of 35. Findings Include: On 6/7/23 at 3:09 PM, R149's electronic health record (EHR) reviewed. R149 was admitted on [DATE]. R149's Quarterly MDS assessment with assessment reference date (ARD) of 10/7/22 was completed on 10/24/22 past the 14 days regulatory timeframe. At 3:24 PM, interviewed V28 (MDS Director) and stated that Quarterly MDS assessment's ARD is set 92 days from the last ARD MDS assessment and should be completed within 7 days from the ARD. V28 stated that scheduling and completion timing of the MDS assessments are based on the RAI manual. [...]
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their policy by not following physician orders for a resident's (R181) enteral feeding for 1 out of 4 residents reviewed in a total sample of 35 residents.
Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that as needed (PRN) psychotropic medication be evaluated if medication is to be extended longer than 14 days for continued use. This failure has the potential to affect one (R78) of five residents reviewed for unnecessary medications in a sample of 35.
Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure a medication error rate of less than 5% for one (R176) of four residents in the sample reviewed for medication administration. There were 25 opportunities and 2 errors resulting in 8% medication error rate.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a functioning call light for 1 (R38) resident out of a total sample of 35 residents.
47 fire safety citations on file: 18 on July 24, 2025, 21 on July 17, 2024, 8 on June 9, 2023.
| Date | Penalty | Amount or length |
|---|---|---|
| June 16, 2026 | Fine | $88,530 |
| March 13, 2026 | Fine | $89,240 |
| March 13, 2026 | Payment Denial | 11 days from April 7, 2026 |
| June 8, 2025 | Fine | $38,071 |
| April 25, 2025 | Fine | $45,212 |
| February 4, 2025 | Fine | $195,940 |
| October 1, 2024 | Fine | $112,151 |
| October 1, 2024 | Payment Denial | 15 days from October 23, 2024 |
| December 1, 2023 | Fine | $26,503 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Illinois | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 2.61 | 3.45 | 3.86 |
| Registered nurses | 0.16 | 0.72 | 0.69 |
| All nursing staff on weekends | 2.37 | 3.07 | 3.42 |
| Nurse aides | 1.68 | ||
| Licensed practical nurses | 0.78 | ||
| Nursing staff turnover (share who left in a year) | 40.8% | 44.5% | 45.8% |
| Registered nurse turnover | 57.1% | 41.8% | 42.9% |
| Administrators who left | 0 |
CMS expects 4.92 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 2.71 on weekdays and 2.37 on weekends, 13% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 1.2% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.17 in April to June 2025 to 2.61 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 2.61 | 0.16 | 2.71 | 2.37 | 1.2% | 0 of 90 | 176 |
| Oct to Dec 2025 | 2.82 | 0.21 | 2.93 | 2.54 | 0.1% | 0 of 92 | 154 |
| Jul to Sep 2025 | 2.91 | 0.24 | 3.05 | 2.57 | 0.1% | 0 of 92 | 150 |
| Apr to Jun 2025 | 3.17 | 0.28 | 3.32 | 2.79 | 0.1% | 0 of 91 | 142 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Illinois, Jan to Mar 2026 | 3.26 | 0.65 | 3.40 | 2.92 | 5.4% | 0.6% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Illinois, all employers | |||
| CNAs (nursing assistants) | $22.10 | $18.95 to $23.26 | 68,640 |
| LPNs and LVNs | $36.06 | $30.57 to $38.25 | 17,440 |
| Registered nurses | $46.15 | $38.47 to $50.94 | 138,910 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Illinois | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 2.1 | 13.4 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.4 | 0.9 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.4 | 1.5 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 1.6 | 3.1 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 2.9 | 2.2 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 3.1 | 14.3 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 4.9 | 4.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 28.6 | 21.7 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 33.9 | 26.1 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 3.0 | 13.8 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.2 | 2.0 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.6 | 2.2 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Landmark at 95th Rehabilitation and Nursing Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (44.3% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
44.3% this home
No different from the national rate
US median of homes 51.5% · Illinois: 106 better, 85 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 28 eligible stays.
10.0% this home
No different from the national rate
US median of homes 10.7% · Illinois: 2 better, 14 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 44 eligible stays.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
US median of homes 7.1% · Illinois: 3 better, 10 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 22 eligible stays.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Illinois50.0% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 12 residents counted.
0.0% this home
Median of homes: Illinois0.3% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 21 residents counted.
3.7% this home
Median of homes: Illinois1.5% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 21 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Illinois100.0% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 6 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: SOUTHPOINT NURSING AND REHABILITATION CENTER LLC. CMS links this home to Infinity Healthcare Consulting, a group of 70 nursing homes averaging 2.1 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| A&f Realty LLC | 5% or greater direct ownership interest | Organization | 10% | 04/01/2009 |
| Brown, Thomeka | W-2 managing employee | Individual | 09/09/2019 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
These are the official offices in Illinois. NursingHomeClear cannot take or act on complaints.