Cycle 1
Health 2025-01-17 · Fire 2025-01-17
17 health deficiencies
Top issue: Nutrition and Dietary (5 deficiencies)
13 fire-safety deficiencies
Top issue: Egress (5 deficiencies)
Chicago, IL
Irving Park Living & Rehab Ctr
1-star overall rating with 2-star inspections with $62,174 in total fines with 17 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
4340 North Keystone, Chicago, IL
(773) 545-8700
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
117
Certified beds
Average residents
86
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1981-01-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.78
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.65
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.11
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.54
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.03
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.78
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
0.58
CMS adjusted RN staffing hours
Adjusted total hours
2.64
CMS adjusted total nurse staffing hours
Case-mix index
1.84
Higher values indicate more complex resident acuity
RN turnover
45%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,544
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.99
Composite VBP score used to determine payment impact.
Payment multiplier
0.9823
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
2.53
Baseline 6.90% · Performance 7.08% · Measure score 2.53 · Achievement 2.53 · Improvement 0
Total nurse turnover
1.76
Baseline 47.62% · Performance 56.48% · Measure score 1.76 · Achievement 1.76 · Improvement 0
Adjusted total nurse staffing
1.70
Baseline 2.54 hours · Performance 3.25 hours · Measure score 1.70 · Achievement 0.62 · Improvement 1.70
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.99% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 32 · Observed rate 21.88% · Lower 95% interval 8.11% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.19 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 76.92% |
95.27%
18.3 pts worse
|
Numerator 20 · Denominator 26 |
| Falls with major injury | 3.85% |
0.77%
3.1 pts worse
|
Numerator 1 · Denominator 26 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 3.85% |
2.29%
1.6 pts worse
|
Numerator 1 · Denominator 26 · Adjusted rate 2.55% |
| Healthcare-associated infections requiring hospitalization | 7.08% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 27 · Observed rate 7.41% · Lower 95% interval 3.92% |
| Staff COVID-19 vaccination coverage | 6.78% |
8.2%
1.4 pts worse
|
Numerator 4 · Denominator 59 |
| Staff flu vaccination coverage | 27.78% |
42%
14.2 pts worse
|
Numerator 25 · Denominator 90 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
2.0
0.6 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.4 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.5 |
2.3
1.2 pts worse
|
1.8
1.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 3.2 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 78.8% |
89.6%
10.8 pts worse
|
93.4%
14.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 78.3% · Q2 76.4% · Q3 70.8% · Q4 88.6% · 4Q avg 78.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.2% |
91.6%
0.4 pts worse
|
95.5%
4.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.2% |
| 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 1.4% · Q2 1.4% · Q3 0.0% · Q4 1.3% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 100.0% |
50.3%
49.7 pts worse
|
11.4%
88.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents who lose too much weight | 0.4% |
6.5%
6.1 pts better
|
5.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.3% |
18.5%
9.2 pts better
|
19.6%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 13.0% · Q3 7.4% · Q4 5.3% · 4Q avg 9.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.9% |
22.8%
9.9 pts better
|
16.7%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 13.9% · Q3 11.4% · Q4 17.9% · 4Q avg 12.9% · 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 | 20.4% |
17.2%
3.2 pts worse
|
16.3%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.5% · Q2 28.3% · Q3 38.7% · Q4 3.6% · 4Q avg 20.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.7% |
15.0%
4.3 pts better
|
14.9%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 20.3% · Q3 11.9% · Q4 3.0% · 4Q avg 10.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.3% |
1.1%
1.2 pts worse
|
1.0%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 2.7% · Q3 2.0% · Q4 0.9% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
1.7%
0.4 pts worse
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 1.4% · Q3 2.9% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.9% |
21.3%
9.4 pts better
|
19.8%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 23.2% · Q3 3.0% · Q4 5.3% · 4Q avg 11.9% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
5.2%
0.6 pts worse
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 3.9% · Q3 7.0% · Q4 10.1% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 57.0% |
68.8%
11.8 pts worse
|
81.7%
24.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 50.0% · Q2 42.1% · Q3 64.4% · Q4 72.5% · 4Q avg 57.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.3% |
14.0%
9.7 pts better
|
12.0%
7.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.3% · Observed 5.0% · Expected 12.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.3% |
2.3%
1 pts worse
|
1.6%
1.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.8% · Q3 5.0% · Q4 5.0% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 65.6% |
63.0%
2.6 pts better
|
79.7%
14.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 65.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.1% |
26.2%
1.9 pts worse
|
23.9%
4.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.1% · Observed 30.0% · Expected 25.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-30 · Fire 2023-11-30
16 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
13 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Cycle 3
Health 2022-12-09 · Fire 2022-12-09
29 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-17
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-02-07
F · Potential for more than minimal harm
2025-01-17
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-02-07
F · Potential for more than minimal harm
2025-01-17
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-02-07
F · Potential for more than minimal harm
2025-01-17
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-02-07
F · Potential for more than minimal harm
2025-01-17
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-02-07
F · Potential for more than minimal harm
2025-01-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-07
F · Potential for more than minimal harm
2025-01-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-02-07
F · Potential for more than minimal harm
2025-01-17
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-02-07
E · Potential for more than minimal harm
2025-01-17
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-02-07
E · Potential for more than minimal harm
2025-01-17
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-17
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-17
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 2025-02-07
D · Potential for more than minimal harm
2025-01-17
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-02-07
F · Potential for more than minimal harm
2023-11-30
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-02-14
F · Potential for more than minimal harm
2023-11-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-07
F · Potential for more than minimal harm
2023-11-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-14
F · Potential for more than minimal harm
2023-11-30
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-02-14
F · Potential for more than minimal harm
2023-11-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-14
E · Potential for more than minimal harm
2023-11-30
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-02-14
E · Potential for more than minimal harm
2023-11-30
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 2024-02-14
E · Potential for more than minimal harm
2023-11-30
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-02-14
E · Potential for more than minimal harm
2023-11-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-14
E · Potential for more than minimal harm
2023-11-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-02-14
E · Potential for more than minimal harm
2023-11-30
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-02-14
D · Potential for more than minimal harm
2023-11-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-14
C · Minimal harm
2023-11-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-14
F · Potential for more than minimal harm
2022-12-09
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-12-15
F · Potential for more than minimal harm
2022-12-09
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2022-12-20
F · Potential for more than minimal harm
2022-12-09
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-12-20
F · Potential for more than minimal harm
2022-12-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-12-14
F · Potential for more than minimal harm
2022-12-09
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-12-14
E · Potential for more than minimal harm
2022-12-09
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 2022-12-21
Inspection history
Recent health citations
G · Actual harm
2025-07-18
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 2025-08-08
G · Actual harm
2025-04-13
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 2025-04-23
F · Potential for more than minimal harm
2025-01-17
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 2025-02-07
F · Potential for more than minimal harm
2025-01-17
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-02-07
F · Potential for more than minimal harm
2025-01-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-07
E · Potential for more than minimal harm
2025-01-17
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 2025-02-07
E · Potential for more than minimal harm
2025-01-17
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 2025-02-07
E · Potential for more than minimal harm
2025-01-17
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 2025-02-07
E · Potential for more than minimal harm
2025-01-17
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 2025-02-07
E · Potential for more than minimal harm
2025-01-17
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2025-02-07
E · Potential for more than minimal harm
2025-01-17
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-17
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-17
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-17
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 2025-02-07
D · Potential for more than minimal harm
2025-01-17
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-17
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2025-02-07
D · Potential for more than minimal harm
2024-12-27
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 2025-01-10
D · Potential for more than minimal harm
2024-12-02
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 2024-12-15
D · Potential for more than minimal harm
2024-11-22
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 2024-12-13
D · Potential for more than minimal harm
2024-08-22
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-09-06
G · Actual harm
2024-05-30
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 2024-06-27
D · Potential for more than minimal harm
2024-05-30
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-06-27
E · Potential for more than minimal harm
2024-01-31
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 2024-02-23
E · Potential for more than minimal harm
2024-01-31
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 2024-02-23
D · Potential for more than minimal harm
2024-01-31
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 2024-02-25
D · Potential for more than minimal harm
2024-01-31
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 2024-02-25
D · Potential for more than minimal harm
2024-01-31
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 2024-02-25
D · Potential for more than minimal harm
2024-01-31
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 2024-02-25
F · Potential for more than minimal harm
2023-11-30
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 2023-12-24
F · Potential for more than minimal harm
2023-11-30
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-12-23
E · Potential for more than minimal harm
2023-11-30
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2023-12-24
D · Potential for more than minimal harm
2023-11-30
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 2023-12-23
D · Potential for more than minimal harm
2023-11-30
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-12-21
D · Potential for more than minimal harm
2023-11-30
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 2023-12-22
D · Potential for more than minimal harm
2023-11-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-23
D · Potential for more than minimal harm
2023-11-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-12-23
D · Potential for more than minimal harm
2023-11-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-12-23
D · Potential for more than minimal harm
2023-11-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-25
D · Potential for more than minimal harm
2023-10-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-27
F · Potential for more than minimal harm
2023-09-02
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 2023-09-08
D · Potential for more than minimal harm
2023-06-30
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 2023-07-28
D · Potential for more than minimal harm
2023-06-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-28
G · Actual harm
2023-06-16
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 2023-07-07
G · Actual harm
2023-06-16
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-07-07
F · Potential for more than minimal harm
2023-06-16
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 2023-07-07
F · Potential for more than minimal harm
2023-06-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-06-16
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 2023-07-07
D · Potential for more than minimal harm
2023-06-16
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 2023-07-07
D · Potential for more than minimal harm
2023-06-16
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 2023-07-07
D · Potential for more than minimal harm
2023-06-16
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 2023-07-07
G · Actual harm
2022-12-09
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 2022-12-10
E · Potential for more than minimal harm
2022-12-09
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2022-12-10
E · Potential for more than minimal harm
2022-12-09
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 2022-12-10
E · Potential for more than minimal harm
2022-12-09
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 2022-12-10
E · Potential for more than minimal harm
2022-12-09
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 2022-12-10
E · Potential for more than minimal harm
2022-12-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-10
D · Potential for more than minimal harm
2022-12-09
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 2022-12-10
D · Potential for more than minimal harm
2022-12-09
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-12-10
D · Potential for more than minimal harm
2022-12-09
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 2022-12-10
D · Potential for more than minimal harm
2022-12-09
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 2022-12-10
D · Potential for more than minimal harm
2022-12-09
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2022-12-10
Penalties and ownership
What sits behind the stars
$15,935
2025-07-18
Fine
Fine · fine $15,935
Fine
$0
2025-07-18
Payment Denial
Payment Denial · denial start 2025-07-18 · 21 days
21 day denial
$46,239
2023-06-16
Fine
Fine · fine $46,239
Fine
$0
2023-06-16
Payment Denial
Payment Denial · denial start 2023-07-08 · 20 days
20 day denial
Ownership
Braunstein, Ephraim
5% Or Greater Direct Ownership Interest · Individual
Klein, Tom
Operational/Managerial Control · Individual
Simons, Sarah
Operational/Managerial Control · Individual
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