Cycle 1
Health 2024-07-13 · Fire 2024-07-13
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
26 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Burnham, IL
Bria Of River Oaks
1-star overall rating with 2-star inspections with abuse icon flag with $270,248 in total fines with 8 recent health deficiencies with 26 fire-safety deficiencies in the latest cycle
14500 South Manistee, Burnham, IL
(708) 862-1260
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
309
Certified beds
Average residents
252
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bria Health Services
Operator or chain grouping
Approved since
1992-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 1 overall / 2 health / 1 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
Hours and turnover
RN hours / resident day
0.44
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.61
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.94
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
2.99
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.05
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
2.58
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.33
CMS adjusted RN staffing hours
Adjusted total hours
2.22
CMS adjusted total nurse staffing hours
Case-mix index
1.84
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
30%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,231
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.91
Composite VBP score used to determine payment impact.
Payment multiplier
0.9902
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.04
Baseline 18.81% · Performance 19.10% · Measure score 5.04 · Achievement 5.04 · Improvement 0
Healthcare-associated infections
4.33
Baseline 5.94% · Performance 6.54% · Measure score 4.33 · Achievement 4.33 · Improvement 0
Total nurse turnover
5.40
Baseline 33.61% · Performance 41.61% · Measure score 5.40 · Achievement 5.40 · Improvement 0
Adjusted total nurse staffing
0
Baseline 1.73 hours · Performance 1.86 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.1% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 58 · Observed rate 3.45% · Lower 95% interval 6.5% |
| Discharge to community | 33.29% |
50.57%
17.3 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 10.71% · Lower 95% interval 18.6% |
| Medicare spending per beneficiary | 1.2 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 97.3% |
95.27%
2 pts better
|
Numerator 36 · Denominator 37 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 37 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 37 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.54% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 30 · Observed rate 3.33% · Lower 95% interval 3.18% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 176 |
| Staff flu vaccination coverage | 69.68% |
42%
27.7 pts better
|
Numerator 131 · Denominator 188 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | 4.17% |
25.2%
21 pts worse
|
Numerator 1 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.0
About the same
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.5 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.3
1 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.5 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
89.6%
10.2 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.6% · Q2 99.6% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.8% |
91.6%
2.2 pts better
|
95.5%
1.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.0% |
3.3%
2.3 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 1.2% · Q3 1.2% · Q4 0.8% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 99.2% |
50.3%
48.9 pts worse
|
11.4%
87.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 99.1% · Q2 99.5% · Q3 100.0% · Q4 98.3% · 4Q avg 99.2% |
| 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 4.3% · Q2 4.3% · Q3 2.5% · Q4 1.3% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.4% |
18.5%
11.1 pts better
|
19.6%
12.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 6.8% · Q3 5.7% · Q4 7.8% · 4Q avg 7.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 38.2% |
22.8%
15.4 pts worse
|
16.7%
21.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 40.4% · Q3 44.4% · Q4 41.7% · 4Q avg 38.2% · 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 | 4.0% |
17.2%
13.2 pts better
|
16.3%
12.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 0.9% · Q3 5.6% · Q4 3.9% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.4% |
15.0%
11.6 pts better
|
14.9%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 3.5% · Q3 3.8% · Q4 1.3% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
1.1%
0.7 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.4% · Q3 0.9% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.2% |
1.7%
1.5 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.4% · Q3 0.0% · Q4 0.4% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.0% |
21.3%
5.3 pts better
|
19.8%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.3% · Q2 16.7% · Q3 14.2% · Q4 13.7% · 4Q avg 16.0% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
5.2%
1.5 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 2.3% · Q3 2.1% · Q4 4.1% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.2% |
68.8%
22.4 pts better
|
81.7%
9.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.2% · Q2 92.7% · Q3 90.5% · Q4 91.2% · 4Q avg 91.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.1% |
14.0%
1.1 pts worse
|
12.0%
3.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.1% · Observed 19.4% · Expected 14.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.9% |
2.3%
0.6 pts worse
|
1.6%
1.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.3% |
63.0%
26.3 pts better
|
79.7%
9.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 36.2% |
26.2%
10 pts worse
|
23.9%
12.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 36.2% · Observed 38.9% · Expected 25.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-03 · Fire 2023-08-03
18 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (9 deficiencies)
Cycle 3
Health 2022-08-05 · Fire 2022-08-05
14 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
38 fire-safety deficiencies
Top issue: Emergency Preparedness (20 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-13
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-07-18
F · Potential for more than minimal harm
2024-07-13
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2024-07-18
F · Potential for more than minimal harm
2024-07-13
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-07-18
F · Potential for more than minimal harm
2024-07-13
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-07-18
F · Potential for more than minimal harm
2024-07-13
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2024-07-18
F · Potential for more than minimal harm
2024-07-13
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Not marked corrected
F · Potential for more than minimal harm
2024-07-13
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 2024-07-18
F · Potential for more than minimal harm
2024-07-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-01
F · Potential for more than minimal harm
2024-07-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-18
F · Potential for more than minimal harm
2024-07-13
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-07-18
F · Potential for more than minimal harm
2024-07-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-07-18
F · Potential for more than minimal harm
2024-07-13
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-07-18
F · Potential for more than minimal harm
2024-07-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-26
E · Potential for more than minimal harm
2024-07-13
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-07-18
E · Potential for more than minimal harm
2024-07-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-07-18
E · Potential for more than minimal harm
2024-07-13
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-07-18
E · Potential for more than minimal harm
2024-07-13
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-07-18
E · Potential for more than minimal harm
2024-07-13
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2024-07-18
E · Potential for more than minimal harm
2024-07-13
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-07-18
E · Potential for more than minimal harm
2024-07-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-08-01
E · Potential for more than minimal harm
2024-07-13
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-09-09
E · Potential for more than minimal harm
2024-07-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-18
E · Potential for more than minimal harm
2024-07-13
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-07-18
E · Potential for more than minimal harm
2024-07-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-07-18
E · Potential for more than minimal harm
2024-07-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-07-18
E · Potential for more than minimal harm
2024-07-13
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2024-07-18
F · Potential for more than minimal harm
2023-08-03
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Not marked corrected
F · Potential for more than minimal harm
2023-08-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-29
F · Potential for more than minimal harm
2023-08-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-23
F · Potential for more than minimal harm
2023-08-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-08-23
F · Potential for more than minimal harm
2023-08-03
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-08-23
F · Potential for more than minimal harm
2023-08-03
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-08-23
E · Potential for more than minimal harm
2023-08-03
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-08-23
E · Potential for more than minimal harm
2023-08-03
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-08-23
E · Potential for more than minimal harm
2023-08-03
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-08-23
E · Potential for more than minimal harm
2023-08-03
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-08-23
E · Potential for more than minimal harm
2023-08-03
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 2023-08-23
E · Potential for more than minimal harm
2023-08-03
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-08-23
E · Potential for more than minimal harm
2023-08-03
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-08-23
D · Potential for more than minimal harm
2023-08-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-08-23
C · Minimal harm
2023-08-03
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-08-23
C · Minimal harm
2023-08-03
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-08-23
F · Potential for more than minimal harm
2022-08-05
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2022-09-05
F · Potential for more than minimal harm
2022-08-05
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2022-09-05
F · Potential for more than minimal harm
2022-08-05
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2022-09-05
F · Potential for more than minimal harm
2022-08-05
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2022-09-05
F · Potential for more than minimal harm
2022-08-05
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2022-09-05
F · Potential for more than minimal harm
2022-08-05
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2022-09-05
F · Potential for more than minimal harm
2022-08-05
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2022-09-05
F · Potential for more than minimal harm
2022-08-05
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2022-09-05
F · Potential for more than minimal harm
2022-08-05
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2022-09-05
F · Potential for more than minimal harm
2022-08-05
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2022-09-05
F · Potential for more than minimal harm
2022-08-05
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2022-09-05
F · Potential for more than minimal harm
2022-08-05
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2022-09-05
F · Potential for more than minimal harm
2022-08-05
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2022-09-05
F · Potential for more than minimal harm
2022-08-05
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2022-09-05
F · Potential for more than minimal harm
2022-08-05
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2022-09-05
F · Potential for more than minimal harm
2022-08-05
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-09-05
F · Potential for more than minimal harm
2022-08-05
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-09-05
F · Potential for more than minimal harm
2022-08-05
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-09-05
F · Potential for more than minimal harm
2022-08-05
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2022-09-05
F · Potential for more than minimal harm
2022-08-05
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2022-09-05
F · Potential for more than minimal harm
2022-08-05
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2022-09-05
F · Potential for more than minimal harm
2022-08-05
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Not marked corrected
F · Potential for more than minimal harm
2022-08-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-09-26
F · Potential for more than minimal harm
2022-08-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-07
F · Potential for more than minimal harm
2022-08-05
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-09-05
F · Potential for more than minimal harm
2022-08-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-09-05
F · Potential for more than minimal harm
2022-08-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-09-09
E · Potential for more than minimal harm
2022-08-05
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-09-05
E · Potential for more than minimal harm
2022-08-05
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-09-05
E · Potential for more than minimal harm
2022-08-05
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 2022-09-05
E · Potential for more than minimal harm
2022-08-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-09-15
E · Potential for more than minimal harm
2022-08-05
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-10-07
E · Potential for more than minimal harm
2022-08-05
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-09-05
E · Potential for more than minimal harm
2022-08-05
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2022-09-05
E · Potential for more than minimal harm
2022-08-05
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2022-09-05
E · Potential for more than minimal harm
2022-08-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-09-05
E · Potential for more than minimal harm
2022-08-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-09-05
E · Potential for more than minimal harm
2022-08-05
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2022-09-05
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-06-24
F584 · Resident Rights Deficiencies
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 2025-06-25
E · Potential for more than minimal harm
2025-06-24
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-06-25
G · Actual harm
2025-04-06
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 2025-04-07
D · Potential for more than minimal harm
2025-04-06
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-04-07
G · Actual harm
2025-03-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-25
G · Actual harm
2025-03-24
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-03-14
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 2025-03-15
G · Actual harm
2024-12-03
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 2024-12-04
E · Potential for more than minimal harm
2024-12-03
F584 · Resident Rights Deficiencies
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 2024-12-04
G · Actual 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 2024-10-11
D · Potential for more than minimal harm
2024-10-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-09-14
F803 · Nutrition and Dietary Deficiencies
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 2024-09-15
G · Actual harm
2024-08-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-02
E · Potential for more than minimal harm
2024-08-01
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-08-02
G · Actual harm
2024-07-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-14
D · Potential for more than minimal harm
2024-06-21
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 2024-06-22
F · Potential for more than minimal harm
2024-06-09
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-06-10
G · Actual harm
2024-05-31
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 2024-06-22
D · Potential for more than minimal harm
2024-05-31
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-06-01
J · Immediate jeopardy
2024-01-09
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 2024-01-10
G · Actual harm
2023-11-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-04
E · Potential for more than minimal harm
2023-11-03
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-11-04
G · Actual harm
2023-08-03
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 2023-08-22
G · Actual harm
2023-08-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-22
G · Actual harm
2023-08-03
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 2023-08-22
F · Potential for more than minimal harm
2023-08-03
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 2023-09-11
F · Potential for more than minimal harm
2023-08-03
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-09-11
F · Potential for more than minimal harm
2023-08-03
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-08-22
E · Potential for more than minimal harm
2023-08-03
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 2023-08-22
D · Potential for more than minimal harm
2023-08-03
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-04-14
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 2023-04-15
D · Potential for more than minimal harm
2023-04-14
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 2023-04-15
D · Potential for more than minimal harm
2023-03-03
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 2023-03-04
F · Potential for more than minimal harm
2022-08-05
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 2022-08-22
E · Potential for more than minimal harm
2022-08-05
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-08-22
E · Potential for more than minimal harm
2022-08-05
F584 · Resident Rights Deficiencies
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 2022-08-22
E · Potential for more than minimal harm
2022-08-05
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2022-08-22
D · Potential for more than minimal harm
2022-08-05
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 2022-08-22
D · Potential for more than minimal harm
2022-08-05
F688 · Quality of Life and Care Deficiencies
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 2022-08-22
D · Potential for more than minimal harm
2022-08-05
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2022-08-22
Penalties and ownership
What sits behind the stars
$22,984
2025-03-14
Fine
Fine · fine $22,984
Fine
$25,604
2024-12-03
Fine
Fine · fine $25,604
Fine
$14,050
2024-10-10
Fine
Fine · fine $14,050
Fine
$30,550
2024-07-13
Fine
Fine · fine $30,550
Fine
$30,602
2024-05-31
Fine
Fine · fine $30,602
Fine
$0
2024-05-31
Payment Denial
Payment Denial · denial start 2024-06-20 · 2 days
2 day denial
$82,833
2024-01-09
Fine
Fine · fine $82,833
Fine
$13,039
2023-11-03
Fine
Fine · fine $13,039
Fine
$50,586
2023-08-03
Fine
Fine · fine $50,586
Fine
$0
2023-08-03
Payment Denial
Payment Denial · denial start 2023-09-01 · 10 days
10 day denial
Ownership
Berkovits, Fred
5% Or Greater Direct Ownership Interest · Individual
Nwagwu Youlo, Chimnoya
Operational/Managerial Control · Individual
Olanrewaju, Rosemary
Operational/Managerial Control · Individual
Segal, Dov
5% Or Greater Direct Ownership Interest · Individual
Segal, Dov
Limited Partnership Interest · Individual
Weinfeld, Avrum
5% Or Greater Direct Ownership Interest · Individual
Weinfeld, Avrum
Operational/Managerial Control · Individual
Weiss, Amy
5% Or Greater Direct Ownership Interest · Individual
Weiss, Daniel
5% Or Greater Direct Ownership Interest · Individual
Weiss, Daniel
Operational/Managerial Control · Individual
Weiss, Natan
5% Or Greater Direct Ownership Interest · Individual
Wheat Chaff LP
5% Or Greater Direct Ownership Interest · Organization
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