Cycle 1
Health 2025-08-13 · Fire 2024-07-19
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Zion, IL
Grove At The Lake,the
2-star overall rating with 3-star inspections with $79,366 in total fines with 9 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
2534 Elim Avenue, Zion, IL
(847) 746-8435
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
244
Certified beds
Average residents
150
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Legacy Healthcare
Operator or chain grouping
Approved since
1989-12-01
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
0.57
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.84
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.90
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.32
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.13
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.57
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
2.37
CMS adjusted total nurse staffing hours
Case-mix index
1.91
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,468
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.67
Composite VBP score used to determine payment impact.
Payment multiplier
0.9856
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.78
Baseline 17.52% · Performance 19.22% · Measure score 4.78 · Achievement 4.78 · Improvement 0
Healthcare-associated infections
5.06
Baseline 9.20% · Performance 6.86% · Measure score 5.06 · Achievement 3.25 · Improvement 5.06
Total nurse turnover
2.03
Baseline 40.00% · Performance 55.38% · Measure score 2.03 · Achievement 2.03 · Improvement 0
Adjusted total nurse staffing
0
Baseline 2.19 hours · Performance 2.28 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.63% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 92 · Observed rate 13.04% · Lower 95% interval 7.16% |
| Discharge to community | 45.78% |
50.57%
4.8 pts worse
|
No Different than the National Rate · Eligible stays 86 · Observed rate 32.56% · Lower 95% interval 33.52% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 79 · Denominator 79 |
| Falls with major injury | 1.27% |
0.77%
0.5 pts worse
|
Numerator 1 · Denominator 79 |
| Discharge self-care score | 53.33% |
53.69%
0.4 pts worse
|
Numerator 24 · Denominator 45 |
| Discharge mobility score | 40% |
50.94%
10.9 pts worse
|
Numerator 18 · Denominator 45 |
| Pressure ulcers or injuries, new or worsened | 2.53% |
2.29%
0.2 pts worse
|
Numerator 2 · Denominator 79 · Adjusted rate 1.7% |
| Healthcare-associated infections requiring hospitalization | 6.86% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 66 · Observed rate 10.61% · Lower 95% interval 4.3% |
| Staff COVID-19 vaccination coverage | 16.34% |
8.2%
8.1 pts better
|
Numerator 25 · Denominator 153 |
| Staff flu vaccination coverage | 91.72% |
42%
49.7 pts better
|
Numerator 133 · Denominator 145 |
| Discharge function score | 51.11% |
56.45%
5.3 pts worse
|
Numerator 23 · Denominator 45 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 35 · Denominator 35 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 40.63% |
25.2%
15.4 pts better
|
Numerator 13 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
2.0
0.5 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 4.0 · Expected 3.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.9 |
2.3
0.6 pts worse
|
1.8
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 3.6 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.1% |
89.6%
3.5 pts better
|
93.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 83.6% · Q2 88.7% · Q3 99.3% · Q4 100.0% · 4Q avg 93.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.9% |
91.6%
1.7 pts worse
|
95.5%
5.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
3.3%
About the same
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 4.5% · Q3 3.7% · Q4 2.7% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 99.4% |
50.3%
49.1 pts worse
|
11.4%
88 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 100.0% · Q3 99.2% · Q4 100.0% · 4Q avg 99.4% |
| Percentage of long-stay residents who lose too much weight | 7.3% |
6.5%
0.8 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 7.0% · Q3 5.9% · Q4 8.7% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.9% |
18.5%
5.4 pts worse
|
19.6%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 25.8% · Q3 22.3% · Q4 22.7% · 4Q avg 23.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.8% |
22.8%
2 pts worse
|
16.7%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.9% · Q2 26.3% · Q3 23.5% · Q4 20.0% · 4Q avg 24.8% · 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 | 4.5% |
17.2%
12.7 pts better
|
16.3%
11.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.0% · Q3 9.2% · Q4 4.8% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.6% |
15.0%
11.4 pts better
|
14.9%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 1.0% · Q3 3.9% · Q4 5.5% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.1%
0.2 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.9% · Q3 0.5% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
1.7%
1.1 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.0% · Q4 1.4% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.3% |
21.3%
5 pts better
|
19.8%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.0% · Q2 18.3% · Q3 13.4% · Q4 12.8% · 4Q avg 16.3% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
5.2%
0.8 pts worse
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 5.2% · Q3 7.3% · Q4 5.9% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 51.3% |
68.8%
17.5 pts worse
|
81.7%
30.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 39.5% · Q2 47.4% · Q3 64.6% · Q4 53.8% · 4Q avg 51.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.0% |
14.0%
1 pts better
|
12.0%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.0% · Observed 16.9% · Expected 14.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.5% |
2.3%
0.2 pts worse
|
1.6%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 0.0% · Q3 2.4% · Q4 3.6% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 58.0% |
63.0%
5 pts worse
|
79.7%
21.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 58.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.0% |
26.2%
5.2 pts better
|
23.9%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.0% · Observed 32.4% · Expected 36.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-19 · Fire 2023-09-27
14 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
14 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Cycle 3
Health 2023-09-27 · Fire 2022-10-19
23 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-19
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-08-06
F · Potential for more than minimal harm
2024-07-19
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2024-08-06
F · Potential for more than minimal harm
2024-07-19
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2024-08-06
F · Potential for more than minimal harm
2024-07-19
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-08-06
F · Potential for more than minimal harm
2024-07-19
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-08-06
F · Potential for more than minimal harm
2024-07-19
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-08-06
F · Potential for more than minimal harm
2024-07-19
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-11-07
F · Potential for more than minimal harm
2024-07-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-07
F · Potential for more than minimal harm
2024-07-19
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-08-06
F · Potential for more than minimal harm
2024-07-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-06
F · Potential for more than minimal harm
2024-07-19
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2024-08-07
F · Potential for more than minimal harm
2024-07-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-14
E · Potential for more than minimal harm
2024-07-19
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-08-06
E · Potential for more than minimal harm
2024-07-19
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-08-05
E · Potential for more than minimal harm
2024-07-19
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 2024-08-06
E · Potential for more than minimal harm
2024-07-19
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-08-06
E · Potential for more than minimal harm
2024-07-19
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-07
F · Potential for more than minimal harm
2023-09-27
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Not marked corrected
F · Potential for more than minimal harm
2023-09-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-10-03
F · Potential for more than minimal harm
2023-09-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-10-03
F · Potential for more than minimal harm
2023-09-27
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-10-04
F · Potential for more than minimal harm
2023-09-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-24
E · Potential for more than minimal harm
2023-09-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-10-03
E · Potential for more than minimal harm
2023-09-27
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-10-03
E · Potential for more than minimal harm
2023-09-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-03
E · Potential for more than minimal harm
2023-09-27
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-09-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-03
F · Potential for more than minimal harm
2022-10-19
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-11-03
F · Potential for more than minimal harm
2022-10-19
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-11-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-12-08
E · Potential for more than minimal harm
2025-11-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-11-15
D · Potential for more than minimal harm
2025-09-22
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-10-01
E · Potential for more than minimal harm
2025-08-13
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 2025-08-14
D · Potential for more than minimal harm
2025-08-13
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 2025-08-14
D · Potential for more than minimal harm
2025-08-13
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 2025-08-14
D · Potential for more than minimal harm
2025-08-13
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-08-14
D · Potential for more than minimal harm
2025-08-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-14
G · Actual harm
2025-08-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-09
D · Potential for more than minimal harm
2024-12-17
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 2024-12-18
J · Immediate jeopardy
2024-08-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-06
E · Potential for more than minimal harm
2024-07-19
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-07-23
E · Potential for more than minimal harm
2024-07-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-23
D · Potential for more than minimal harm
2024-07-19
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-07-23
D · Potential for more than minimal harm
2024-07-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-19
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 2024-07-23
D · Potential for more than minimal harm
2024-07-19
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 2024-07-23
D · Potential for more than minimal harm
2024-07-19
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-07-23
D · Potential for more than minimal harm
2024-07-19
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-07-23
D · Potential for more than minimal harm
2024-07-19
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 2024-07-23
D · Potential for more than minimal harm
2024-07-19
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 2024-07-23
E · Potential for more than minimal harm
2024-07-15
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 2024-07-20
D · Potential for more than minimal harm
2024-07-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-20
D · Potential for more than minimal harm
2024-01-08
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 2024-01-10
D · Potential for more than minimal harm
2024-01-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-10
D · Potential for more than minimal harm
2023-12-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-12-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-10
G · Actual harm
2023-09-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-27
F · Potential for more than minimal harm
2023-09-27
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 2023-10-27
E · Potential for more than minimal harm
2023-09-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-09-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-09-27
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-09-27
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 2023-09-29
D · Potential for more than minimal harm
2023-09-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-09-27
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 2023-09-29
D · Potential for more than minimal harm
2023-09-27
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 2023-09-29
D · Potential for more than minimal harm
2023-09-27
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-09-27
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-08-03
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-08-04
D · Potential for more than minimal harm
2023-08-03
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 2023-08-04
D · Potential for more than minimal harm
2023-08-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-04
D · Potential for more than minimal harm
2023-06-09
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 2023-06-12
D · Potential for more than minimal harm
2023-05-17
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 2023-05-19
D · Potential for more than minimal harm
2023-05-08
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 2023-05-09
D · Potential for more than minimal harm
2023-03-23
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 2023-03-24
D · Potential for more than minimal harm
2023-03-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-24
Penalties and ownership
What sits behind the stars
$0
2025-09-05
Payment Denial
Payment Denial · denial start 2025-12-05 · 53 days
53 day denial
$19,920
2025-08-08
Fine
Fine · fine $19,920
Fine
$30,014
2024-07-15
Fine
Fine · fine $30,014
Fine
$29,432
2023-09-27
Fine
Fine · fine $29,432
Fine
$0
2023-09-27
Payment Denial
Payment Denial · denial start 2023-10-20 · 7 days
7 day denial
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
Grove At The Lake Realty, LLC
5% Or Greater Security Interest · Organization
Legacy Healthcare Financial Services LLC
Operational/Managerial Control · Organization
Shabat, Menachem
Operational/Managerial Control · Individual
Stangel, Julie
Operational/Managerial Control · Individual
Vnb New York LLC
Operational/Managerial Control · Organization
Vnb New York LLC
5% Or Greater Security Interest · Organization
Woike, Tom
Operational/Managerial Control · Individual
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