14 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Palos Heights, IL
3-star overall rating with 3-star inspections with $39,805 in total fines with 13 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
11860 Southwest Highway, Palos Heights, IL
(708) 361-4555
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
130
Certified beds
Average residents
88
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Legacy Healthcare
Operator or chain grouping
Approved since
1996-06-12
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
1.16
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.38
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.05
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.58
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.53
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.42
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
1.12
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.87
CMS adjusted RN staffing hours
Adjusted total hours
2.70
CMS adjusted total nurse staffing hours
Case-mix index
1.82
Higher values indicate more complex resident acuity
RN turnover
41%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
66%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Program rank
9,212
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.43
Composite VBP score used to determine payment impact.
Payment multiplier
0.9835
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
3.67
Baseline 22.61% · Performance 20.28% · Measure score 3.67 · Achievement 2.48 · Improvement 3.67
Healthcare-associated infections
6.11
Baseline 6.64% · Performance 6.01% · Measure score 6.11 · Achievement 6.11 · Improvement 3.32
Total nurse turnover
0
Baseline 65.57% · Performance 66.98% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.45 hours · Performance 2.51 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.08% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 283 · Observed rate 13.07% · Lower 95% interval 9.39% |
| Discharge to community | 55.07% |
50.57%
4.5 pts better
|
No Different than the National Rate · Eligible stays 304 · Observed rate 46.71% · Lower 95% interval 49.92% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 95.12% |
95.27%
0.1 pts worse
|
Numerator 78 · Denominator 82 |
| Falls with major injury | 1.22% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 82 |
| Discharge self-care score | 63.64% |
53.69%
10 pts better
|
Numerator 21 · Denominator 33 |
| Discharge mobility score | 57.58% |
50.94%
6.6 pts better
|
Numerator 19 · Denominator 33 |
| Pressure ulcers or injuries, new or worsened | 3.66% |
2.29%
1.4 pts worse
|
Numerator 3 · Denominator 82 · Adjusted rate 2.5% |
| Healthcare-associated infections requiring hospitalization | 6.01% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 116 · Observed rate 4.31% · Lower 95% interval 3.5% |
| Staff COVID-19 vaccination coverage | 0.72% |
8.2%
7.5 pts worse
|
Numerator 1 · Denominator 139 |
| Staff flu vaccination coverage | 93.88% |
42%
51.9 pts better
|
Numerator 184 · Denominator 196 |
| Discharge function score | 54.55% |
56.45%
1.9 pts worse
|
Numerator 18 · Denominator 33 |
| Transfer of health information to provider | 98.08% |
95.95%
2.1 pts better
|
Numerator 51 · Denominator 52 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 24% |
25.2%
1.2 pts worse
|
Numerator 6 · Denominator 25 |
Quality measures
| 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 · Adjusted 2.7 · Observed 3.4 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
2.3
0.4 pts worse
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.9 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.1% |
89.6%
4.5 pts better
|
93.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 95.0% · Q3 86.9% · Q4 96.2% · 4Q avg 94.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.0% |
91.6%
1.4 pts better
|
95.5%
2.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
3.3%
1.7 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 5.0% · Q3 6.0% · Q4 3.8% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 94.9% |
50.3%
44.6 pts worse
|
11.4%
83.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 93.0% · Q2 94.7% · Q3 97.4% · Q4 94.3% · 4Q avg 94.9% |
| Percentage of long-stay residents who lose too much weight | 9.9% |
6.5%
3.4 pts worse
|
5.4%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 11.6% · Q3 8.7% · Q4 11.5% · 4Q avg 9.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 4.0% |
18.5%
14.5 pts better
|
19.6%
15.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 2.8% · Q3 4.3% · Q4 3.2% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.9% |
22.8%
3.9 pts better
|
16.7%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 21.1% · Q3 17.0% · Q4 19.6% · 4Q avg 18.9% · 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 | 21.7% |
17.2%
4.5 pts worse
|
16.3%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.7% · Q2 25.3% · Q3 19.1% · Q4 15.7% · 4Q avg 21.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.5% |
15.0%
2.5 pts worse
|
14.9%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 27.9% · Q3 9.5% · Q4 12.3% · 4Q avg 17.5% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · 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 1.2% · 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 | 27.8% |
21.3%
6.5 pts worse
|
19.8%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.6% · Q2 24.5% · Q3 27.7% · Q4 40.2% · 4Q avg 27.8% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
5.2%
0.2 pts better
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 6.5% · Q3 5.5% · Q4 4.8% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 73.3% |
68.8%
4.5 pts better
|
81.7%
8.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 82.5% · Q2 62.3% · Q3 67.0% · Q4 80.4% · 4Q avg 73.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.0% |
14.0%
6 pts better
|
12.0%
4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.0% · Observed 8.0% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.1% |
2.3%
0.8 pts worse
|
1.6%
1.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.3% · Q3 4.5% · Q4 6.0% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 64.0% |
63.0%
1 pts better
|
79.7%
15.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 64.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.5% |
26.2%
3.7 pts better
|
23.9%
1.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.5% · Observed 24.0% · Expected 25.5% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Quality of Life and Care (5 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Resident Rights (4 deficiencies)
9 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-22
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-09-21
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2023-09-21
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-09-21
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-21
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-09-21
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-21
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-09-21
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-21
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-09-21
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 2023-09-21
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-21
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-27
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2022-07-27
Fire Safety
Provide primary/alternate means for communication.
Corrected 2022-07-27
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-08-12
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-08-15
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-07-28
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-06-30
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-08-15
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2022-07-08
Fire Safety
Ensure proper storage of liquid oxygen.
Corrected 2022-07-08
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-01-19
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2026-01-19
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2026-01-19
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-06-19
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-16
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 2025-06-16
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-07
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-06
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-06
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-12-06
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 2024-12-06
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-06
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-12-06
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-12-06
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-10-04
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-16
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-03-16
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-16
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-09-18
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 2023-09-18
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-09-18
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-09-18
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-18
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-18
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-18
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-09-01
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2023-09-01
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-09-01
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-17
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-06-22
Health
Provide and implement an infection prevention and control program.
Corrected 2022-06-22
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-06-22
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-06-22
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-06-22
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-06-22
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2022-05-31
Health
Keep all essential equipment working safely.
Corrected 2022-06-22
Penalties and ownership
Fine · fine $23,870
Fine
Fine · fine $15,935
Fine
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
W-2 Managing Employee · Individual
Operational/Managerial Control · Organization
Corporate Officer · Individual
Nearby options
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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
Palos Hills, IL
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Chicago Ridge, IL
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $607,418 in total fines with 20 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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