17 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Palos Heights, IL
2-star overall rating with 2-star inspections with $29,168 in total fines with 17 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
7850 West College Drive, Palos Heights, IL
(708) 361-6990
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
184
Certified beds
Average residents
144
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Legacy Healthcare
Operator or chain grouping
Approved since
1989-03-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
90 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.96
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.20
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.94
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.74
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.77
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.87
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.78
CMS adjusted RN staffing hours
Adjusted total hours
3.18
CMS adjusted total nurse staffing hours
Case-mix index
1.69
Higher values indicate more complex resident acuity
RN turnover
54%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Program rank
12,315
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.91
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 22.72% · Performance 23.21% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.85
Baseline 8.78% · Performance 7.51% · Measure score 2.85 · Achievement 1.08 · Improvement 2.85
Total nurse turnover
1.17
Baseline 52.94% · Performance 58.90% · Measure score 1.17 · Achievement 1.17 · Improvement 0
Adjusted total nurse staffing
1.15
Baseline 3.23 hours · Performance 3.40 hours · Measure score 1.15 · Achievement 1.15 · Improvement 0.17
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.8% |
10.72%
2.1 pts worse
|
Worse than the National Rate · Eligible stays 588 · Observed rate 13.61% · Lower 95% interval 10.79% |
| Discharge to community | 58.22% |
50.57%
7.6 pts better
|
Better than the National Rate · Eligible stays 665 · Observed rate 49.47% · Lower 95% interval 53.19% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.94% |
95.27%
3.7 pts better
|
Numerator 373 · Denominator 377 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 377 |
| Discharge self-care score | 42.05% |
53.69%
11.6 pts worse
|
Numerator 111 · Denominator 264 |
| Discharge mobility score | 48.86% |
50.94%
2.1 pts worse
|
Numerator 129 · Denominator 264 |
| Pressure ulcers or injuries, new or worsened | 0.53% |
2.29%
1.8 pts better
|
Numerator 2 · Denominator 377 · Adjusted rate 0.43% |
| Healthcare-associated infections requiring hospitalization | 7.51% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 411 · Observed rate 7.79% · Lower 95% interval 5.38% |
| Staff COVID-19 vaccination coverage | 1.63% |
8.2%
6.6 pts worse
|
Numerator 3 · Denominator 184 |
| Staff flu vaccination coverage | 48.85% |
42%
6.9 pts better
|
Numerator 106 · Denominator 217 |
| Discharge function score | 45.45% |
56.45%
11 pts worse
|
Numerator 120 · Denominator 264 |
| Transfer of health information to provider | 93.94% |
95.95%
2 pts worse
|
Numerator 93 · Denominator 99 |
| Transfer of health information to patient | 98.37% |
96.28%
2.1 pts better
|
Numerator 241 · Denominator 245 |
| Resident COVID-19 vaccinations up to date | 4.64% |
25.2%
20.6 pts worse
|
Numerator 9 · Denominator 194 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.0
0.1 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.7 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.3
0.9 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.6 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 67.7% |
89.6%
21.9 pts worse
|
93.4%
25.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 67.0% · Q2 64.1% · Q3 70.8% · Q4 68.8% · 4Q avg 67.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 76.0% |
91.6%
15.6 pts worse
|
95.5%
19.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 76.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
3.3%
1.4 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 2.2% · Q3 1.1% · Q4 1.1% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 67.6% |
50.3%
17.3 pts worse
|
11.4%
56.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 61.7% · Q2 65.9% · Q3 72.0% · Q4 70.5% · 4Q avg 67.6% |
| Percentage of long-stay residents who lose too much weight | 30.9% |
6.5%
24.4 pts worse
|
5.4%
25.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.8% · Q2 35.4% · Q3 23.1% · Q4 33.7% · 4Q avg 30.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.7% |
18.5%
10.8 pts better
|
19.6%
11.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 4.9% · Q3 7.6% · Q4 8.0% · 4Q avg 7.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.1% |
22.8%
3.7 pts better
|
16.7%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 18.2% · Q3 18.5% · Q4 19.4% · 4Q avg 19.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.9% |
17.2%
2.3 pts better
|
16.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.3% · Q2 9.2% · Q3 15.4% · Q4 10.6% · 4Q avg 14.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.7% |
15.0%
12.7 pts worse
|
14.9%
12.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 18.2% · Q3 51.3% · Q4 33.3% · 4Q avg 27.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
1.1%
0.1 pts better
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 1.9% · Q3 0.7% · Q4 0.7% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
1.7%
0.5 pts worse
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 2.2% · Q3 2.3% · Q4 1.1% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.1% |
21.3%
2.8 pts worse
|
19.8%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.4% · Q2 27.3% · Q3 15.6% · Q4 26.5% · 4Q avg 24.1% |
| Percentage of long-stay residents with pressure ulcers | 8.2% |
5.2%
3 pts worse
|
5.1%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 10.0% · Q3 8.3% · Q4 7.1% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 31.6% |
68.8%
37.2 pts worse
|
81.7%
50.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 22.3% · Q2 31.0% · Q3 35.4% · Q4 36.9% · 4Q avg 31.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.2% |
14.0%
2.8 pts better
|
12.0%
0.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.2% · Observed 11.3% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.8% |
2.3%
0.5 pts worse
|
1.6%
1.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.8% · Q3 2.6% · Q4 1.9% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 28.0% |
63.0%
35 pts worse
|
79.7%
51.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 28.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.5% |
26.2%
3.3 pts worse
|
23.9%
5.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.5% · Observed 29.8% · Expected 24.1% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (9 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (9 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (7 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2024-11-18
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2024-11-18
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-11-18
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-18
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-11-18
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-01-16
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-19
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-01-16
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-17
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-17
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-03-17
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-17
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-03-17
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-03-17
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-17
Fire Safety
Ensure proper storage of liquid oxygen.
Corrected 2023-03-17
Inspection history
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2026-01-19
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-10-10
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-10-10
Health
Dispose of garbage and refuse properly.
Corrected 2025-10-10
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-10
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-10-10
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-10-10
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-10
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-10-10
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-10-10
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-10-10
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-10-10
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-10-10
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-10-10
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-10-10
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-18
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-07-18
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-19
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-11-19
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-19
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-11-19
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-19
Health
Post nurse staffing information every day.
Corrected 2024-11-19
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-28
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-28
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-09-23
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-23
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-23
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-26
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-07-05
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-07-05
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-14
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-01-12
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-01-12
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-12
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-01-12
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-12
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-01-12
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-08
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-09-08
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-02
Penalties and ownership
Fine · fine $19,135
Fine
Fine · fine $10,033
Fine
Payment Denial · denial start 2024-11-05 · 14 days
14 day denial
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
W-2 Managing Employee · Individual
Corporate Officer · Individual
Nearby options
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