South Elgin Living & Rehab Center
746 West Spring Street, South Elgin, IL 60177 · Kane County · 90 certified beds · avg 56 residents/day · certified since Mar 15, 1995
Part of chain: LINEAGE HEALTHCARE (5 facilities, chain avg rating 1.6★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Feb 1, 2024 · F-0584 · triggered by a complaint
The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Why it matters: An unsafe or unclean environment affects residents' health, comfort, and dignity every single day.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Feb 1, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jul 8, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 29, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · May 31, 2024 · F-0758
The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Why it matters: Unneeded psychiatric medications can leave residents overly sedated and raise the risk of falls and other serious harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 28, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Apr 25, 2024 · F-0825 · triggered by a complaint
The facility did not provide or arrange specialized rehabilitation services — such as physical, occupational, or speech therapy — for residents who needed them.
Why it matters: Without needed therapy, a resident may fail to recover strength or skills they could have regained.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 31, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (49)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Aug 14, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 14, 2025 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 14, 2025 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Aug 14, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Aug 14, 2025 | D · Potential for harm, one-off | The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. |
| Aug 14, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jul 8, 2025 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Sep 13, 2024 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Sep 13, 2024 | D · Potential for harm, one-off | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint |
| Aug 14, 2024 | E · Potential for harm, repeated | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint |
| Jun 13, 2024 | F · Potential for harm, facility-wide | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. · from a complaint |
| Jun 13, 2024 | E · Potential for harm, repeated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. · from a complaint |
| May 31, 2024 | ▲ G · Actual harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| May 31, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 31, 2024 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| May 31, 2024 | E · Potential for harm, repeated | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. |
| May 31, 2024 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| May 31, 2024 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| May 31, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| May 31, 2024 | E · Potential for harm, repeated | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| May 31, 2024 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| May 31, 2024 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. |
| May 31, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| May 31, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| May 31, 2024 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| May 31, 2024 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| May 31, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| May 31, 2024 | D · Potential for harm, one-off | The facility did not have a policy covering how food brought in by family and visitors is used and stored safely. |
| Apr 25, 2024 | ▲ G · Actual harm, one-off | The facility did not provide or arrange specialized rehabilitation services — such as physical, occupational, or speech therapy — for residents who needed them. · from a complaint |
| Apr 25, 2024 | F · Potential for harm, facility-wide | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. · from a complaint |
| Apr 25, 2024 | F · Potential for harm, facility-wide | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · from a complaint |
| Apr 25, 2024 | F · Potential for harm, facility-wide | The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. · from a complaint |
| Mar 6, 2024 | F · Potential for harm, facility-wide | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Mar 6, 2024 | D · Potential for harm, one-off | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint |
| Mar 6, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Feb 25, 2024 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Feb 14, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Feb 1, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Feb 1, 2024 | F · Potential for harm, facility-wide | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · from a complaint |
| Feb 1, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Sep 20, 2023 | E · Potential for harm, repeated | The facility did not make sure residents actually saw their doctor face-to-face at all required visits. Doctors must examine nursing home residents in person on a regular schedule. · from a complaint |
| Jun 8, 2023 | D · Potential for harm, one-off | The facility did not honor residents' right to share a room with their spouse or a roommate of their choosing, or moved residents to a different room without written notice beforehand. |
| Jun 8, 2023 | D · Potential for harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. |
| Jun 8, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Jun 8, 2023 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Jun 8, 2023 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Jun 8, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jun 8, 2023 | D · Potential for harm, one-off | The facility did not provide or arrange specialized rehabilitation services — such as physical, occupational, or speech therapy — for residents who needed them. |
| Jun 8, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (16 → 6).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 9 | 0 | E |
| 2024 | 33 | 3 | K ▲ |
| 2025 | 7 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $231,656, plus 2 Medicare payment denial periods.
| Date | Type | Amount / length |
|---|---|---|
| Jul 8, 2025 | Fine | $83,335 |
| Jul 8, 2025 | Payment Denial | 36 days from Aug 6, 2025 |
| Feb 1, 2024 | Fine | $148,321 |
| Feb 1, 2024 | Payment Denial | 152 days from Mar 1, 2024 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Illinois avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.51 | 2.99 | 3.95 | bottom 37% in Illinois; bottom 4% in the U.S. |
| Registered Nurse hours | 0.79 | 0.63 | 0.69 | top 22% in Illinois; top 28% in the U.S. |
| Weekend total nurse staffing | 2.21 | 2.67 | 3.50 | bottom 35% in Illinois; bottom 4% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.87 | 0.56 | 0.48 | top 15% in Illinois; top 9% in the U.S. |
| Total nursing staff turnover (%) | 24.5 | 44.5 | 45.8 | top 7% in Illinois; top 6% in the U.S. |
| RN turnover (%) | 25.0 | 41.8 | 42.9 | top 23% in Illinois; top 20% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.18, RN 1.01, weekend 2.81. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 2/5 · short-stay residents: —/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Braunstein, Ephraim | Individual | Managing Control - Governing Body | NOT APPLICABLE | 12/01/2024 |
| Braunstein, Ephraim | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2024 |
| Braunstein, Ephraim | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2024 |
| Claussen, Mary | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2024 |
| Claussen, Mary | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2024 |
| Diena, Aharon | Individual | Managing Control - Governing Body | NOT APPLICABLE | 12/01/2024 |
| Diena, Aharon | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2024 |
| Diena, Aharon | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2024 |
| Klein, Tom | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2024 |
| Klein, Tom | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2024 |
| Maher, Jayne | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2024 |
| Maher, Jayne | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2024 |
| Parkway Bank and Trust Company | Organization | 5% or Greater Security Interest | NOT APPLICABLE | 12/01/2024 |
| Petlin Holdings LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 12/01/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your approach to psychiatric medications — how do you try non-drug options first and work to reduce doses over time?"
- "How are therapy services provided here, and how quickly does therapy start after a doctor orders it?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Tower Hill Healthcare Center | 0.2 mi | South Elgin, IL | ★☆☆☆☆ | 2/5 | abuse |
| The Pearl of Fox River Valley | 2.8 mi | Elgin, IL | ★★★☆☆ | 3/5 | |
| Crescent Care of Elgin | 2.8 mi | Elgin, IL | ★★★★☆ | 4/5 | |
| River View Rehab Center | 2.8 mi | Elgin, IL | ★★☆☆☆ | 2/5 | abuse |
| Aperion Care Fox River | 2.9 mi | Elgin, IL | ★★★★★ | 5/5 | |
| Aperion Care Elgin | 3.0 mi | Elgin, IL | ★★★☆☆ | 3/5 | |
| Pearl of Elgin, the | 4.2 mi | Elgin, IL | ★★★★☆ | 3/5 | |
| Highland Oaks | 4.4 mi | Elgin, IL | ★★★★★ | 5/5 | |
| Pearl of St Charles, the | 4.9 mi | St Charles, IL | ★☆☆☆☆ | 2/5 | |
| Alpine Care of St. Charles LLC | 4.9 mi | Saint Charles, IL | ★★★☆☆ | 3/5 | |
| Hearthwood SNF Senior Living | 5.6 mi | Bartlett, IL | ★★★★★ | 5/5 | |
| Avondale Estates of Elgin | 6.1 mi | Elgin, IL | ★★★★★ | 5/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 145825.