12 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Bloomingdale, IL
3-star overall rating with 3-star inspections with $73,867 in total fines with 12 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
165 South Bloomingdale Road, Bloomingdale, IL
(630) 980-8700
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
166
Certified beds
Average residents
104
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Legacy Healthcare
Operator or chain grouping
Approved since
1989-07-13
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
0.90
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.66
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.96
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.52
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.56
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.29
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.85
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.70
CMS adjusted RN staffing hours
Adjusted total hours
2.73
CMS adjusted total nurse staffing hours
Case-mix index
1.77
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Program rank
8,848
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.48
Composite VBP score used to determine payment impact.
Payment multiplier
0.9838
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
2.37
Baseline 23.50% · Performance 21.64% · Measure score 2.37 · Achievement 0 · Improvement 2.37
Healthcare-associated infections
4.07
Baseline 7.59% · Performance 6.62% · Measure score 4.07 · Achievement 4.07 · Improvement 3.25
Total nurse turnover
3.75
Baseline 54.67% · Performance 48.35% · Measure score 3.75 · Achievement 3.75 · Improvement 1.62
Adjusted total nurse staffing
0
Baseline 2.64 hours · Performance 2.68 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.23% |
10.72%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 203 · Observed rate 13.79% · Lower 95% interval 9.06% |
| Discharge to community | 50.84% |
50.57%
0.3 pts better
|
No Different than the National Rate · Eligible stays 221 · Observed rate 45.25% · Lower 95% interval 45.21% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 81 · Denominator 81 |
| Falls with major injury | 1.23% |
0.77%
0.5 pts worse
|
Numerator 1 · Denominator 81 |
| Discharge self-care score | 72.55% |
53.69%
18.9 pts better
|
Numerator 37 · Denominator 51 |
| Discharge mobility score | 68.63% |
50.94%
17.7 pts better
|
Numerator 35 · Denominator 51 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 81 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.62% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 90 · Observed rate 5.56% · Lower 95% interval 3.64% |
| Staff COVID-19 vaccination coverage | 3.09% |
8.2%
5.1 pts worse
|
Numerator 3 · Denominator 97 |
| Staff flu vaccination coverage | 78.46% |
42%
36.5 pts better
|
Numerator 102 · Denominator 130 |
| Discharge function score | 68.63% |
56.45%
12.2 pts better
|
Numerator 35 · Denominator 51 |
| Transfer of health information to provider | 96.15% |
95.95%
0.2 pts better
|
Numerator 25 · Denominator 26 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 36 · Denominator 36 |
| Resident COVID-19 vaccinations up to date | 86.96% |
25.2%
61.8 pts better
|
Numerator 40 · Denominator 46 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
89.6%
9.3 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.9% · Q4 96.6% · 4Q avg 98.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.9% |
91.6%
6.3 pts better
|
95.5%
2.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
3.3%
1.6 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.2% · Q3 1.1% · Q4 2.2% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 98.2% |
50.3%
47.9 pts worse
|
11.4%
86.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 97.6% · Q2 100.0% · Q3 97.5% · Q4 97.5% · 4Q avg 98.2% |
| Percentage of long-stay residents who lose too much weight | 3.1% |
6.5%
3.4 pts better
|
5.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 5.3% · Q3 0.0% · Q4 2.4% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.3% |
18.5%
6.2 pts better
|
19.6%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 13.8% · Q3 11.4% · Q4 13.1% · 4Q avg 12.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.7% |
22.8%
3.1 pts better
|
16.7%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 19.4% · Q3 22.0% · Q4 16.1% · 4Q avg 19.7% · 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 | 15.5% |
17.2%
1.7 pts better
|
16.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.2% · Q2 9.1% · Q3 16.1% · Q4 11.5% · 4Q avg 15.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.7% |
15.0%
0.7 pts worse
|
14.9%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.1% · Q2 18.4% · Q3 11.7% · Q4 11.0% · 4Q avg 15.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.1%
0.8 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.7%
1.4 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.7% |
21.3%
6.4 pts worse
|
19.8%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 36.1% · Q3 27.7% · Q4 30.1% · 4Q avg 27.7% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
5.2%
0.6 pts worse
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 7.2% · Q3 3.2% · Q4 5.8% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.4% |
68.8%
22.6 pts better
|
81.7%
9.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 92.3% · Q3 89.2% · Q4 89.4% · 4Q avg 91.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 24.3% |
14.0%
10.3 pts worse
|
12.0%
12.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.3% · Observed 23.5% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
2.3%
0.9 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 2.4% · Q4 1.4% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 77.1% |
63.0%
14.1 pts better
|
79.7%
2.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 77.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.6% |
26.2%
0.4 pts worse
|
23.9%
2.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.6% · Observed 25.9% · Expected 23.2% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (7 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (9 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (7 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-17
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-03-17
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-17
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-03-17
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-17
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-04-08
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 2024-04-08
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-08
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-04-08
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-08
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-05-08
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-05-08
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 2023-05-08
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-05-08
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-14
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-05
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-06-05
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-06-05
Health
Ensure 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.
Corrected 2025-03-11
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-11
Health
Honor 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.
Corrected 2025-03-11
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-03-11
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-11
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-11
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 2025-03-11
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-01
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-10-30
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 2024-10-30
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-11
Health
Ensure 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.
Corrected 2024-10-11
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-04-26
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-04-03
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-04-03
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-03
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-03
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-04-03
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-04-30
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-24
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-15
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-11-15
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-28
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-07-10
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-06-19
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-08
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-05-08
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-05-08
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-05-10
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 2023-05-08
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-05-08
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-19
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-05-08
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-05-10
Health
Honor 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.
Corrected 2023-05-16
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-05-16
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 2023-05-16
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-05-16
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-05-08
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-04-05
Penalties and ownership
Fine · fine $15,935
Fine
Fine · fine $10,384
Fine
Fine · fine $47,548
Fine
Payment Denial · denial start 2023-05-23 · 48 days
48 day denial
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Individual
W-2 Managing Employee · Individual
Operational/Managerial Control · Organization
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