Cycle 1
Health 2025-04-11 · Fire 2025-04-11
18 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Chicago, IL
Carlton At The Lake, The
2-star overall rating with 2-star inspections with $241,131 in total fines with 18 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
725 West Montrose Avenue, Chicago, IL
(773) 929-1700
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
244
Certified beds
Average residents
168
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Legacy Healthcare
Operator or chain grouping
Approved since
1990-06-13
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
Hours and turnover
RN hours / resident day
0.76
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.71
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.81
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.28
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.47
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.11
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.74
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
0.55
CMS adjusted RN staffing hours
Adjusted total hours
2.39
CMS adjusted total nurse staffing hours
Case-mix index
1.88
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,310
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.03
Composite VBP score used to determine payment impact.
Payment multiplier
0.9833
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.15% · Performance 22.67% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.57
Baseline 10.65% · Performance 8.91% · Measure score 2.57 · Achievement 0 · Improvement 2.57
Total nurse turnover
6.17
Baseline 44.95% · Performance 38.46% · Measure score 6.17 · Achievement 6.17 · Improvement 2.73
Adjusted total nurse staffing
0.87
Baseline 1.91 hours · Performance 2.44 hours · Measure score 0.87 · Achievement 0 · Improvement 0.87
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.61% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 118 · Observed rate 8.47% · Lower 95% interval 6.69% |
| Discharge to community | 37.68% |
50.57%
12.9 pts worse
|
Worse than the National Rate · Eligible stays 110 · Observed rate 28.18% · Lower 95% interval 29.84% |
| Medicare spending per beneficiary | 1.44 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 54 · Denominator 54 |
| Falls with major injury | 3.7% |
0.77%
2.9 pts worse
|
Numerator 2 · Denominator 54 |
| Discharge self-care score | 33.33% |
53.69%
20.4 pts worse
|
Numerator 10 · Denominator 30 |
| Discharge mobility score | 20% |
50.94%
30.9 pts worse
|
Numerator 6 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 3.7% |
2.29%
1.4 pts worse
|
Numerator 2 · Denominator 54 · Adjusted rate 3.08% |
| Healthcare-associated infections requiring hospitalization | 8.91% |
7.12%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 50 · Observed rate 14% · Lower 95% interval 4.82% |
| Staff COVID-19 vaccination coverage | 1.39% |
8.2%
6.8 pts worse
|
Numerator 2 · Denominator 144 |
| Staff flu vaccination coverage | 71.17% |
42%
29.2 pts better
|
Numerator 116 · Denominator 163 |
| Discharge function score | 46.67% |
56.45%
9.8 pts worse
|
Numerator 14 · Denominator 30 |
| 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 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 67.74% |
25.2%
42.5 pts better
|
Numerator 21 · Denominator 31 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
2.0
0.6 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 2.2 · Expected 2.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
2.3
0.3 pts better
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.3 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.7% |
89.6%
3.1 pts better
|
93.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 86.2% · Q2 93.9% · Q3 97.6% · Q4 93.1% · 4Q avg 92.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.2% |
91.6%
5.6 pts better
|
95.5%
1.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.5% |
3.3%
1.8 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.6% · Q3 1.2% · Q4 3.1% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 99.5% |
50.3%
49.2 pts worse
|
11.4%
88.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 100.0% · Q3 100.0% · Q4 98.6% · 4Q avg 99.5% |
| Percentage of long-stay residents who lose too much weight | 7.8% |
6.5%
1.3 pts worse
|
5.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 7.9% · Q3 8.6% · Q4 6.9% · 4Q avg 7.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.9% |
18.5%
7.6 pts better
|
19.6%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 8.6% · Q3 12.6% · Q4 12.8% · 4Q avg 10.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 26.6% |
22.8%
3.8 pts worse
|
16.7%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 28.7% · Q3 25.5% · Q4 25.2% · 4Q avg 26.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 3.5% |
0.1%
3.4 pts worse
|
0.1%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 3.6% · Q3 3.6% · Q4 2.5% · 4Q avg 3.5% |
| Percentage of long-stay residents whose ability to walk independently worsened | 3.5% |
17.2%
13.7 pts better
|
16.3%
12.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 3.3% · Q3 3.0% · Q4 0.0% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.3% |
15.0%
11.7 pts better
|
14.9%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 3.6% · Q3 7.4% · Q4 1.5% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.2% |
1.1%
2.1 pts worse
|
1.0%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 2.5% · Q3 4.3% · Q4 1.8% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.7%
0.9 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.6% · Q4 2.6% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 2.2% |
21.3%
19.1 pts better
|
19.8%
17.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.9% · Q3 1.9% · Q4 3.3% · 4Q avg 2.2% |
| Percentage of long-stay residents with pressure ulcers | 8.1% |
5.2%
2.9 pts worse
|
5.1%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 6.9% · Q3 9.3% · Q4 8.2% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 39.6% |
68.8%
29.2 pts worse
|
81.7%
42.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 32.5% · Q2 51.1% · Q3 51.2% · Q4 24.5% · 4Q avg 39.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.6% |
14.0%
7.4 pts better
|
12.0%
5.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.6% · Observed 7.3% · Expected 12.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
2.3%
0.7 pts better
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 2.2% · Q4 2.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 70.5% |
63.0%
7.5 pts better
|
79.7%
9.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 70.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.8% |
26.2%
5.6 pts worse
|
23.9%
7.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.8% · Observed 30.9% · Expected 23.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-15 · Fire 2024-03-15
17 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-02-03 · Fire 2023-02-03
25 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-11
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-04-16
F · Potential for more than minimal harm
2025-04-11
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-05-14
F · Potential for more than minimal harm
2025-04-11
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-04-16
E · Potential for more than minimal harm
2025-04-11
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 2025-04-16
F · Potential for more than minimal harm
2024-03-15
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Not marked corrected
F · Potential for more than minimal harm
2024-03-15
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-03-14
E · Potential for more than minimal harm
2024-03-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-14
C · Minimal harm
2024-03-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-14
F · Potential for more than minimal harm
2023-02-03
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2023-02-09
F · Potential for more than minimal harm
2023-02-03
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Not marked corrected
F · Potential for more than minimal harm
2023-02-03
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-02-09
F · Potential for more than minimal harm
2023-02-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-09
F · Potential for more than minimal harm
2023-02-03
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2023-02-09
E · Potential for more than minimal harm
2023-02-03
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-02-09
E · Potential for more than minimal harm
2023-02-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-02-09
E · Potential for more than minimal harm
2023-02-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-02-09
E · Potential for more than minimal harm
2023-02-03
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-02-09
E · Potential for more than minimal harm
2023-02-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-02-09
D · Potential for more than minimal harm
2023-02-03
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-02-09
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-11-21
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-11-22
D · Potential for more than minimal harm
2025-11-21
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-11-22
D · Potential for more than minimal harm
2025-11-07
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-11-08
D · Potential for more than minimal harm
2025-09-08
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-09-09
D · Potential for more than minimal harm
2025-09-08
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 2025-09-09
F · Potential for more than minimal harm
2025-08-25
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-08-26
D · Potential for more than minimal harm
2025-08-25
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-08-26
G · Actual harm
2025-05-02
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 2025-05-03
D · Potential for more than minimal harm
2025-05-02
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-05-03
E · Potential for more than minimal harm
2025-04-11
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 2025-04-12
E · Potential for more than minimal harm
2025-04-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-12
E · Potential for more than minimal harm
2025-04-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-12
D · Potential for more than minimal harm
2025-04-11
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-04-12
D · Potential for more than minimal harm
2025-04-11
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-04-12
D · Potential for more than minimal harm
2025-04-11
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 2025-04-12
D · Potential for more than minimal harm
2025-04-11
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-04-12
D · Potential for more than minimal harm
2025-04-11
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-04-12
D · Potential for more than minimal harm
2025-04-11
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-04-12
D · Potential for more than minimal harm
2024-11-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-11-07
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 2024-11-08
D · Potential for more than minimal harm
2024-08-05
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-08-05
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-08-06
E · Potential for more than minimal harm
2024-04-15
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-04-16
D · Potential for more than minimal harm
2024-04-15
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2024-04-16
D · Potential for more than minimal harm
2024-04-15
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-04-16
G · Actual harm
2024-03-15
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-03-16
E · Potential for more than minimal harm
2024-03-15
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-03-16
E · Potential for more than minimal harm
2024-03-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-16
E · Potential for more than minimal harm
2024-03-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-16
E · Potential for more than minimal harm
2024-03-15
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-03-16
E · Potential for more than minimal harm
2024-03-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-03-15
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-03-15
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-03-15
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-03-15
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-03-16
G · Actual harm
2024-01-19
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 2024-02-03
D · Potential for more than minimal harm
2024-01-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-02-03
D · Potential for more than minimal harm
2023-12-08
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-12-20
G · Actual harm
2023-11-02
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 2023-11-03
F · Potential for more than minimal harm
2023-11-02
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-11-03
E · Potential for more than minimal harm
2023-11-02
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 2023-11-03
D · Potential for more than minimal harm
2023-11-02
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-11-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-03
J · Immediate jeopardy
2023-10-04
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 2023-10-17
G · Actual harm
2023-10-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-17
F · Potential for more than minimal harm
2023-10-04
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-10-17
E · Potential for more than minimal harm
2023-07-01
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 2023-07-14
D · Potential for more than minimal harm
2023-07-01
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 2023-07-14
G · Actual harm
2023-05-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-09
D · Potential for more than minimal harm
2023-05-08
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-05-09
D · Potential for more than minimal harm
2023-05-08
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 2023-05-09
D · Potential for more than minimal harm
2023-05-08
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-05-09
F · Potential for more than minimal harm
2023-02-03
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 2023-02-04
E · Potential for more than minimal harm
2023-02-03
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-02-04
E · Potential for more than minimal harm
2023-02-03
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-02-04
E · Potential for more than minimal harm
2023-02-03
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2023-02-04
D · Potential for more than minimal harm
2023-02-03
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 2023-02-04
D · Potential for more than minimal harm
2023-02-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-04
D · Potential for more than minimal harm
2023-02-03
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-02-04
D · Potential for more than minimal harm
2023-02-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-04
Penalties and ownership
What sits behind the stars
$16,822
2024-03-15
Fine
Fine · fine $16,822
Fine
$16,052
2024-01-19
Fine
Fine · fine $16,052
Fine
$11,180
2023-11-02
Fine
Fine · fine $11,180
Fine
$0
2023-11-02
Payment Denial
Payment Denial · denial start 2023-11-25 · 25 days
25 day denial
$197,077
2023-10-04
Fine
Fine · fine $197,077
Fine
Ownership
Chaim Rajchenbach Descendants Tr Ua 04282008
5% Or Greater Direct Ownership Interest · Organization
Doros Generation Trust U/A/D 1/3/12
5% Or Greater Direct Ownership Interest · Organization
Carlton Associates Limited Partnership
5% Or Greater Security Interest · Organization
Shabat, Menachem
Corporate Officer · Individual
Ventrella, Joanne
W-2 Managing Employee · Individual
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