Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Sheriden Commons during CMS and state inspections, most recent first.
Surveyors found that the call light system on the second and third floors did not provide an adequate audible alert, as call lights activated in several rooms only illuminated the hallway lights above doors without producing a sound that could be heard at the nurses’ station or down the hallway. A resident reported long delays in call light response and stated the unit call light had been broken for an extended period. CNAs confirmed they could not hear call lights from the nurses’ station or while inside other rooms and instead relied on visually checking hallway lights. The DON reported the system had been in place for months with visual lights as the primary alert, and the Maintenance Director acknowledged the audible signal at the end of the hallway was very low and not audible with background noise.
Two residents with morbid obesity, multiple comorbidities, intact cognition, and dependence on staff for toileting hygiene reported that the incontinence briefs supplied did not fit because the facility only stocked up to size 3 XL, despite their need for larger sizes per product guidelines. One resident, weighing about 350 pounds, stated that briefs did not fit and that staff told residents these were the only sizes available. Another resident, weighing about 450 pounds and typically wearing size 4–5 XL, reported that after a change in supply company and management, her usual sizes were no longer ordered, and the current products were too small and not absorbent, even though size 3 XL bags were present in her room. CNAs confirmed that the largest size available was 3 XL and noted occasional supply issues, while facility policies stated residents’ rights to reasonable accommodation of their needs and preferences.
The facility failed to ensure proper infection control measures, including the use of PPE during high-contact care for residents on Enhanced Barrier Precautions, the absence of EBP signage and PPE bins, and the lack of sanitization of medication trays between residents. These deficiencies were observed during wound care and medication administration, potentially affecting all residents on the affected floors.
A facility failed to ensure Low Air Loss Mattresses (LALM) were set correctly for four residents, leading to potential harm. Residents with varying cognitive impairments and medical conditions had mattresses set at incorrect weights, contrary to facility policy. This oversight was identified through observations and interviews, highlighting a significant deficiency in pressure ulcer prevention.
The facility failed to properly store and label medications, affecting multiple residents. A nurse did not label multidose medications with open and discard dates, and an unopened insulin vial was not refrigerated as required. The refrigerator used for medication storage was not within the acceptable temperature range, potentially compromising medication efficacy. Additionally, an unattended and unlocked treatment cart was observed, posing a risk of unauthorized access. The DON acknowledged these issues and the associated risks.
The facility failed to serve hot foods at the required temperature of 135 degrees F, affecting residents on the third floor. Despite initial appropriate food temperatures, delays in serving led to a drop in temperature, with a test tray showing pork and vegetables below the standard. Staffing issues during meal service contributed to the deficiency, as only one CNA was initially observed passing trays, contrary to facility policy.
A facility failed to maintain the dignity of a resident with an indwelling catheter by not covering the catheter drainage bag with a privacy bag. The drainage bag was observed facing the resident's door without a cover, which was confirmed by the Assistant Director of Nursing. The resident had a history of cerebral infarction and other conditions, with a moderately impaired cognitive status. The facility's policy requires catheter bags to be covered to ensure resident dignity.
A facility failed to assess and authorize a resident's self-administration of medication. The resident had Trimove oral drops and Calamine lotion at their bedside without a physician's order or proper assessment. The staff was unaware of the medications, and the facility's policy requires notifying the doctor and assessing the resident's ability to self-administer medication safely. The resident's cognitive status was intact, but there was no documented order for self-administration in the electronic health record.
The facility failed to properly manage respiratory care equipment for two residents, both cognitively intact and with significant respiratory conditions. One resident's BIPAP mask was left uncontained, while another's nasal cannula was found on the floor, undated and not contained. The facility's policies require such equipment to be stored in plastic bags when not in use and dated when changed, which was not followed.
A resident with moderate cognitive impairment and multiple health issues has not received dental services in over six years while living in the facility. The resident's teeth were observed to have a black substance and multiple holes. The DON acknowledged the resident's dental issues and the difficulty in securing dental appointments for Medicaid patients, despite the facility's policy requiring routine dental services.
A resident with metastatic cancer experienced untreated left arm pain and a fracture for 34 days due to the facility's failure to review x-ray results and communicate with the physician. The resident's pain was not properly assessed or documented, and there was confusion over a lidocaine patch order, which the attending physician did not authorize.
A resident with multiple health conditions, including chronic respiratory failure and morbid obesity, was hospitalized due to acute kidney injury and fecal impaction after the facility failed to properly monitor fluid intake and bowel output. Despite having a care plan that required monitoring intake and output, the facility did not perform these assessments unless on fluid restriction. Staff interviews revealed a lack of communication and adherence to care plans, contributing to the resident's critical health issues.
Inadequate Audible Call Light Function on Upper-Floor Units
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all portions of the call light system were functioning so that call lights could be heard away from the nurses’ station on the second and third floors. A resident reported that call light response times varied depending on staff and that at times the call light remained on for 20–30 minutes; the resident also stated that the call light on the unit had been broken for about two months. The facility’s policy required that call lights at each bedside, toilet, and bathing facility relay to staff or a centralized location to ensure appropriate response, but the system in place did not consistently provide an audible alert that could be heard throughout the unit. On multiple occasions, surveyors tested the call light system on the third floor and found that while the light above residents’ doors illuminated, there was no audible sound heard from the nurses’ station or from other areas on the unit. When the call light was activated near one resident’s room, the light above the door turned on but no sound was heard at the nurses’ station approximately 30 feet away. When another resident’s call light was activated, surveyors and a CNA confirmed that no sound could be heard from the nurses’ station, and there were no additional speakers in the hallway to increase the volume of the call light signal. Additional testing of call lights for other residents showed the same pattern: the visual light outside the room illuminated, but the sound from the call light system at the nurses’ station could not be heard. CNAs reported that they relied on frequently checking the hallway lights above residents’ doors because they could not hear the call light sound from the nurses’ station or from inside another resident’s room. The DON stated that the call light system had been in place for more than six months, included a hallway light and an audible sound at the nurses’ station, and that the visual light outside each resident’s door was considered the primary alerting mechanism. The Maintenance Director stated that the call light should generally be heard by all staff on the unit, but acknowledged that the audible sound at the far end of the hallway near the nurses’ station was very low and could not be heard if there was any background noise.
Failure to Provide Correctly Sized Incontinence Products for Obese, Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences for correctly sized incontinence products. Surveyors found that the facility only ordered up to size 3 extra-large briefs and protective underwear, despite residents measuring as needing larger sizes per the incontinence product brand’s guidelines. One resident, who reported weighing about 350 pounds and having morbid obesity, heart failure, chronic kidney disease, difficulty walking, and dependence on staff for toileting hygiene, stated that the briefs provided by the facility did not fit and that residents were told these were the only sizes available. This resident had intact cognition per a BIMS score of 14 and care plans documenting functional limitations, dependence for toileting, and bladder/bowel incontinence related to morbid obesity and other diagnoses. Another resident, who reported weighing about 450 pounds and typically wearing size 4–5 extra-large, stated that her incontinence product size was no longer available after the facility changed companies and that the current product was too small and not absorbent. This resident had diagnoses including respiratory failure with hypoxia, type 2 diabetes mellitus, asthma, and morbid obesity, with care plans documenting bowel and bladder incontinence and dependence on staff for toileting hygiene, and a BIMS score of 15 indicating intact cognition. Surveyors observed two bags of size 3 extra-large briefs in this resident’s room, despite her report of needing larger sizes. CNAs reported that the largest size available was 3 extra-large and that there were occasional issues obtaining size 3, 4, or 5 products if shipments arrived late. Facility policies on accommodation of needs and resident rights stated that residents have the right to reasonable accommodation of their needs and preferences, but the ordering practices and available stock did not provide appropriately sized incontinence products for these residents.
Infection Control Deficiencies in PPE Use and Medication Handling
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were in place, as evidenced by several observations and interviews. Staff did not don appropriate PPE while providing high-contact care to residents on Enhanced Barrier Precautions (EBP). Specifically, a registered nurse and a certified nursing assistant entered a resident's room without wearing gowns to perform wound care, and hand hygiene was not performed during the procedure. Additionally, a Purewick canister was observed on the floor, which is against infection control protocols. Further deficiencies were noted in the absence of EBP signage and PPE bins outside the rooms of residents who required them. This was observed for two residents who had wounds or indwelling catheters, and the lack of signage and PPE availability was acknowledged by the Assistant Director of Nursing. The absence of these precautions could lead to cross-contamination and infection spread among residents and staff. The facility also failed to sanitize a medication tray between uses for different residents. A licensed practical nurse was observed preparing medications for one resident and then using the same unsanitized tray for another resident, which is against the facility's infection control expectations. This oversight was recognized by the Director of Nursing, who admitted there was no specific policy for sanitizing medication trays but acknowledged the importance of doing so to prevent cross-contamination.
Improper LALM Settings for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that Low Air Loss Mattresses (LALM) for pressure ulcer prevention were set at the correct weight settings for four residents. This deficiency was identified through observation, interview, and record review. The residents affected included those with varying degrees of cognitive impairment and medical conditions that increased their risk for pressure ulcers. For instance, one resident with a Braden scale score indicating moderate risk had their mattress set for a weight significantly higher than their actual weight, which could lead to inadequate pressure relief. Another resident, with severe cognitive impairment and a high risk for pressure ulcers, was found to have their mattress set at a weight much higher than their actual weight. This discrepancy was noted by a Licensed Practical Nurse who was unaware of the reason for the incorrect setting. The Director of Nursing acknowledged that incorrect settings could cause harm by making the mattress too firm. Additionally, a resident with a stage 4 pressure ulcer was found to have their mattress set too low, causing it to deflate and become less firm, which the resident reported as uncomfortable. The facility's policy required that LALMs be set according to the manufacturer's guidelines based on the resident's weight and desired firmness. However, the survey revealed that staff did not consistently adhere to these guidelines, leading to potential harm for residents at risk of pressure ulcers. The failure to properly adjust the LALM settings according to the residents' weights and needs was a significant oversight in the care provided to these residents.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication storage and labeling protocols, affecting multiple residents. During a survey, it was observed that a registered nurse on the second floor did not label multidose medications with open and discard dates, specifically for Dorzolamide and Timolol eye drops, and a Glargine vial. Additionally, an unopened Novolin R vial was not stored in the refrigerator as required by the pharmacy's auxiliary label. The Director of Nursing confirmed that the facility's policy mandates labeling multidose medications with open dates to ensure timely disposal and maintaining unopened insulin vials in the refrigerator to preserve potency. Further inspection revealed that the refrigerator used for medication storage on the second floor was not maintaining the required temperature range. The thermometer inside the refrigerator registered a temperature of 52°F, exceeding the acceptable range of 36°F to 46°F. This improper storage condition could potentially compromise the efficacy of medications stored within, including insulin vials and Tubersol for TB tests. The Director of Nursing acknowledged the importance of maintaining the correct temperature to ensure medication potency. Additionally, the surveyor observed an unattended and unlocked treatment cart on the third floor while the Director of Nursing was performing wound care in a resident's room. The facility's policy requires that treatment carts be locked when not in use to prevent unauthorized access and potential harm to residents. The Director of Nursing admitted that the cart should have been locked and recognized the risk of residents accessing medication solutions, which could lead to poisoning.
Failure to Serve Hot Foods at Required Temperature
Penalty
Summary
The facility failed to serve hot foods to residents at the required temperature of 135 degrees Fahrenheit, as per their policy. During a resident council meeting, multiple residents reported that their food was cold when served. Observations on the same day revealed that while the food was initially at appropriate temperatures before plating, the process of serving the food led to a significant drop in temperature. Specifically, a test tray served to residents on the third floor showed that the rice was at 135 degrees F, but the pork and vegetables were at 120 degrees F and 116 degrees F, respectively, which is below the facility's standard. The deficiency was further compounded by staffing issues during meal service. Only one CNA was observed passing lunch trays to residents in their rooms, which took approximately 8 minutes before additional help arrived. The Director of Nursing later stated that there should have been more than one person passing trays, as all CNAs, nurses, and staff are responsible for this task. The facility's policy and job descriptions indicate that hot foods should be served at 135 degrees F or higher, and CNAs are responsible for assisting with meal service, highlighting a lapse in adherence to these guidelines.
Failure to Maintain Resident Dignity with Uncovered Catheter Bag
Penalty
Summary
The facility failed to ensure the dignity of a resident with an indwelling catheter by not covering the catheter drainage bag with a privacy bag. This deficiency was observed during a survey when the drainage bag was found facing the resident's door without a privacy cover. The Assistant Director of Nursing/Infection Preventionist confirmed the observation and acknowledged that the drainage bag should have been covered to maintain the resident's privacy. The resident affected by this deficiency had a history of cerebral infarction, benign prostatic hyperplasia, neuromuscular dysfunction of the bladder, and obstructive and reflux uropathy. The resident's cognitive status was moderately impaired, as indicated by a BIMS score of 09. The facility's policy on dignity explicitly states that urinary catheter bags should be covered to promote the resident's sense of well-being and self-esteem, which was not adhered to in this instance.
Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
The facility failed to complete a Medication Self-Administration Safety Screen Assessment and did not obtain a physician's order for a resident to self-administer medication and treatment. This deficiency was identified during an observation where a resident had Trimove oral drops and Calamine lotion on their bedside table. The resident stated that they used the Trimove as a vitamin and the Calamine lotion for itching due to heparin shots. The registered nurse present was unaware of why the resident had these medications and confirmed that the facility's policy requires notifying the doctor, care planning, and assessing the resident's ability to self-administer medication safely. Further investigation revealed that the resident's primary care physician was not informed about the medications at the bedside, and there was no order for self-administration of the Trimove oral drops. The resident's cognitive status was intact, as indicated by a BIMS score of 15, but the facility did not document an order for self-administration of the medications in the electronic health record. The facility's policy requires that all medications to be self-administered should be ordered by a doctor, and any medications found at the bedside without authorization should be returned to the nurse in charge.
Improper Management of Respiratory Equipment for Two Residents
Penalty
Summary
The facility failed to properly manage and contain respiratory care equipment for two residents, leading to deficiencies in their care. One resident, who has a history of Chronic Obstructive Pulmonary Disease (COPD), pneumonia, acute respiratory distress, heart failure, and dependence on supplemental oxygen, was observed with a BIPAP mask left uncontained on a nightstand. This resident is cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15. The facility's active orders indicated the use of BIPAP at nighttime every shift, yet the equipment was not stored properly when not in use. Another resident, also cognitively intact with a BIMS score of 15, has diagnoses including COPD, respiratory failure, congestive heart failure, bronchiolitis, and Respiratory Syncytial Virus (RSV). This resident's nasal cannula was found on the floor, undated, and not contained, despite active orders for oxygen use as needed for shortness of breath. The facility's Director of Nursing confirmed that oxygen equipment should be stored in a plastic bag when not in use to prevent contamination and that tubing should be dated when changed. The facility's policies and job descriptions for RNs and LPNs emphasize the importance of maintaining high-quality care in accordance with standards and regulations, which were not adhered to in these instances.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services for a resident, identified as R54, who has been living in the facility since 2019. R54, a [AGE] year old with diagnoses including cognitive communication deficit, cellulitis, dysphagia, hemiplegia, and hemiparesis following cerebral infarction, has a BIMS score of 12, indicating moderate impairment. During an investigation, a surveyor observed that R54 had a black substance on his teeth and multiple teeth with small holes. R54 reported not having received dental services in over six years. The Director of Nursing (DON) acknowledged that R54's teeth appeared discolored and decayed but noted that R54 did not report any pain. The DON also mentioned difficulties in securing dental appointments for Medicaid patients, despite the facility's policy stating that routine and emergency dental services should be available according to the resident's assessment and plan of care. R54's assessment indicated a need for maximal assistance with oral hygiene.
Failure to Address Resident's New Pain and Fracture
Penalty
Summary
The facility failed to identify and treat the cause of new pain in a resident's left arm, resulting in harm due to a left humerus fracture that went untreated for 34 days. The resident, who had a diagnosis of metastatic cancer of unknown origin, experienced significant left arm pain and limited mobility. Despite the resident's complaints of pain and the presence of a fracture, the facility did not timely review x-ray results or communicate these results to the physician. The resident's x-ray was ordered on 06/25/24 due to pain, but the results were not reviewed until 07/19/24. During this period, there was no documentation of an SBAR (situation, background, assessment, and recommendation) for the new pain, nor was there evidence that the physician or the resident's next of kin were notified. The facility's policies on pain management and change in condition were not followed, as the resident's new pain was not properly assessed or communicated. Additionally, there was confusion regarding the prescription of a lidocaine patch for the resident's pain, with the attending physician denying having ordered it. The facility's staff did not adhere to protocols for entering physician orders, as evidenced by the unauthorized use of the physician's name for the lidocaine order. This lack of communication and adherence to protocol contributed to the resident's prolonged pain and untreated fracture.
Failure to Monitor Fluid and Bowel Output Leads to Resident Hospitalization
Penalty
Summary
The facility failed to properly assess and manage the oral fluid intake, urinary output, and bowel output of a resident (R4) who was at risk for dehydration. This deficiency resulted in harm to R4, who required hospitalization for acute kidney injury and fecal impaction. R4 had a history of major depressive disorder, chronic respiratory failure, chronic obstructive pulmonary disease, morbid obesity, venous insufficiency, and sleep apnea. Despite having an intact cognition with a BIMS score of 13, R4 was not adequately monitored for fluid intake and output, as the facility did not perform intake and output measurements unless the resident was on fluid restriction. The care plan for R4 included monitoring and documenting intake and output, but this was not followed, leading to critical health issues. Interviews with staff revealed that there was a lack of communication and adherence to care plans. The RN stated that care plans are checked monthly or every two months, and the LPN mentioned that CNAs are supposed to notify nurses about bowel movements, but this could be missed if not asked. The DON confirmed that the facility does not routinely perform intake and output monitoring, and the expectation is for staff to follow care plans 100%. The CNA reported that they chart bowel movements in the computer, but there was no consistent follow-up by nurses. R4's preference for diet cola over water was noted, and despite being encouraged to drink more water, R4's fluid intake was not adequately managed, contributing to the resident's hospitalization for dehydration-related complications.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mado Healthcare - Uptown | 0.2 mi | — | 0 | 0 |
| Complete Care At Margate Park | 0.7 mi | — | 10 | 0 |
| Alden Lakeland Rehab & Hcc | 0.8 mi | — | 13 | 1 |
| Aperion Care Wesley | 0.8 mi | — | 3 | 0 |
| Selfhelp Home Of Chicago | 0.8 mi | — | 0 | 0 |
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