Cycle 1
Health 2024-10-10 · Fire 2024-10-10
15 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Elmhurst, IL
Elmhurst Extended Care Center
1-star overall rating with 1-star inspections with $133,134 in total fines with 15 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
200 East Lake Street, Elmhurst, IL
(630) 516-5000
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
108
Certified beds
Average residents
51
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
1.46
Registered nurse staffing
LPN hours / resident day
0.50
Licensed practical nurse staffing
Aide hours / resident day
2.15
Nurse aide staffing
Weekend hours
3.70
Weekend nurse staffing
RN turnover
53%
Annual RN turnover
Total nurse turnover
48%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
2.0
0.7 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.2 |
2.3
0.9 pts worse
|
1.8
1.4 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 82.8% |
89.6%
6.8 pts worse
|
93.4%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 84.4% |
91.6%
7.2 pts worse
|
95.5%
11.1 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
3.3%
1 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 25.2% |
50.3%
25.1 pts better
|
11.4%
13.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 8.1% |
6.5%
1.6 pts worse
|
5.4%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.8% |
18.5%
8.7 pts better
|
19.6%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 37.2% |
22.8%
14.4 pts worse
|
16.7%
20.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 19.9% |
17.2%
2.7 pts worse
|
16.3%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.9% |
15.0%
1.9 pts worse
|
14.9%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.1%
1.1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
1.7%
0.7 pts worse
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.2% |
21.3%
5.9 pts worse
|
19.8%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
5.2%
2.2 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 80.2% |
68.8%
11.4 pts better
|
81.7%
1.5 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 28.6% |
14.0%
14.6 pts worse
|
12.0%
16.6 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.2% |
2.3%
0.9 pts worse
|
1.6%
1.6 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 72.5% |
63.0%
9.5 pts better
|
79.7%
7.2 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 38.3% |
26.2%
12.1 pts worse
|
23.9%
14.4 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-29 · Fire 2023-11-29
17 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2022-11-17 · Fire 2022-11-17
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
18 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-25
E · Potential for more than minimal harm
2024-10-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-25
E · Potential for more than minimal harm
2024-10-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-25
E · Potential for more than minimal harm
2024-10-10
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-10-25
F · Potential for more than minimal harm
2023-11-29
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-12-05
F · Potential for more than minimal harm
2023-11-29
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-12-06
F · Potential for more than minimal harm
2023-11-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-12-06
F · Potential for more than minimal harm
2023-11-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-12-06
F · Potential for more than minimal harm
2023-11-29
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-12-06
F · Potential for more than minimal harm
2023-11-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-06
E · Potential for more than minimal harm
2023-11-29
K321 · Smoke Deficiencies
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 2023-12-06
E · Potential for more than minimal harm
2023-11-29
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-06
E · Potential for more than minimal harm
2023-11-29
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2023-12-06
E · Potential for more than minimal harm
2023-11-29
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-12-06
E · Potential for more than minimal harm
2023-11-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-06
E · Potential for more than minimal harm
2023-11-29
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-12-06
F · Potential for more than minimal harm
2022-11-17
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2022-11-21
F · Potential for more than minimal harm
2022-11-17
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2022-11-21
F · Potential for more than minimal harm
2022-11-17
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-11-21
F · Potential for more than minimal harm
2022-11-17
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-11-30
F · Potential for more than minimal harm
2022-11-17
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-11-21
F · Potential for more than minimal harm
2022-11-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-09
F · Potential for more than minimal harm
2022-11-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-11-21
F · Potential for more than minimal harm
2022-11-17
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2022-12-23
F · Potential for more than minimal harm
2022-11-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-29
E · Potential for more than minimal harm
2022-11-17
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-11-21
E · Potential for more than minimal harm
2022-11-17
K321 · Smoke Deficiencies
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 2022-11-21
E · Potential for more than minimal harm
2022-11-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-11-21
E · Potential for more than minimal harm
2022-11-17
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-11-21
E · Potential for more than minimal harm
2022-11-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-09
E · Potential for more than minimal harm
2022-11-17
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-11-21
E · Potential for more than minimal harm
2022-11-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-11-21
E · Potential for more than minimal harm
2022-11-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-11-21
E · Potential for more than minimal harm
2022-11-17
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-11-21
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-08
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-02-06
D · Potential for more than minimal harm
2026-01-08
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2026-02-06
E · Potential for more than minimal harm
2025-05-09
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-02-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-07
G · Actual harm
2024-10-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-17
G · Actual harm
2024-10-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-10-17
F · Potential for more than minimal harm
2024-10-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-17
F · Potential for more than minimal harm
2024-10-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-27
F · Potential for more than minimal harm
2024-10-10
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-10-17
E · Potential for more than minimal harm
2024-10-10
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-12-27
E · Potential for more than minimal harm
2024-10-10
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-10-10
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-10-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-10-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-10-10
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-10-10
F761 · Pharmacy Service Deficiencies
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 2024-10-17
D · Potential for more than minimal harm
2024-09-18
F578 · Resident Rights Deficiencies
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 2024-10-01
D · Potential for more than minimal harm
2024-09-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-01
G · Actual harm
2024-08-30
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-10
D · Potential for more than minimal harm
2024-08-30
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-09-10
D · Potential for more than minimal harm
2024-08-30
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-09-10
D · Potential for more than minimal harm
2024-07-15
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2024-12-10
J · Immediate jeopardy
2024-06-05
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-06-06
E · Potential for more than minimal harm
2024-06-05
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-06-06
F · Potential for more than minimal harm
2023-11-29
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-04-01
F · Potential for more than minimal harm
2023-11-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-05
F · Potential for more than minimal harm
2023-11-29
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-04-09
D · Potential for more than minimal harm
2023-11-29
F657 · Resident Assessment and Care Planning Deficiencies
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 2023-12-05
D · Potential for more than minimal harm
2023-11-29
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-12-05
D · Potential for more than minimal harm
2023-11-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-12-05
D · Potential for more than minimal harm
2023-11-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-05
D · Potential for more than minimal harm
2023-11-29
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-12-05
E · Potential for more than minimal harm
2022-11-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-11
D · Potential for more than minimal harm
2022-11-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-01-11
D · Potential for more than minimal harm
2022-11-17
F690 · Quality of Life and Care Deficiencies
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 2023-01-11
Penalties and ownership
What sits behind the stars
$0
2026-01-08
Payment Denial
Payment Denial · denial start 2026-01-30 · 7 days
7 day denial
$68,842
2024-07-15
Fine
Fine · fine $68,842
Fine
$0
2024-07-15
Payment Denial
Payment Denial · denial start 2024-09-20 · 98 days
98 day denial
$64,292
2024-06-05
Fine
Fine · fine $64,292
Fine
$0
2023-11-29
Payment Denial
Payment Denial · denial start 2024-01-24 · 76 days
76 day denial
Ownership
Matthew, Sanju
5% Or Greater Direct Ownership Interest · Individual
Dave, Madhusudan
5% Or Greater Direct Ownership Interest · Individual
Mathew, Soji
5% Or Greater Direct Ownership Interest · Individual
Simon, Thomas
5% Or Greater Direct Ownership Interest · Individual
Thomas, Jose
5% Or Greater Direct Ownership Interest · Individual
Thomas, Mathew
5% Or Greater Direct Ownership Interest · Individual
Dave, Dipti
5% Or Greater Direct Ownership Interest · Individual
Cyriac, Anish
5% Or Greater Direct Ownership Interest · Individual
Advance Inpatient Medicine LLC
Operational/Managerial Control · Organization
Alex, Shijy
Corporate Director · Individual
Cdh Cpa Pllc
Operational/Managerial Control · Organization
Clinical Nutrition Consulting Services, LLC
Operational/Managerial Control · Organization
Dave, Dipti
Corporate Officer · Individual
Dave, Love
Operational/Managerial Control · Individual
Dave, Love
Corporate Director · Individual
Dave, Madhusudan
Corporate Officer · Individual
Elevate Therapy Consulting Group, LLC
Operational/Managerial Control · Organization
Inspire Consulting Services, LLC
Operational/Managerial Control · Organization
Matthew, Sanju
Corporate Officer · Individual
Siddique, Mohammad
Operational/Managerial Control · Individual
Thadathil Chacko, Mibin
Corporate Director · Individual
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#3
Bridgeway Senior Living
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1-star overall rating with 2-star inspections with $24,448 in total fines with 22 recent health deficiencies
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