Cycle 1
Health 2025-01-30 · Fire 2025-01-30
31 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Chicago, IL
Kenwood Vlge Nrsg And Rhb Ctr
1-star overall rating with 1-star inspections with abuse icon flag with $234,787 in total fines with 31 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
4505 South Drexel, Chicago, IL
(773) 285-0550
Overall
1 / 5
CMS overall stars
Health inspections
1 / 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
155
Certified beds
Average residents
138
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1995-01-23
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
0.36
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.97
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.88
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.21
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
2.74
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.20
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
0.25
CMS adjusted RN staffing hours
Adjusted total hours
2.25
CMS adjusted total nurse staffing hours
Case-mix index
1.95
Higher values indicate more complex resident acuity
RN turnover
77%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,191
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.52
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
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
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
1.65
Baseline 70.75% · Performance 60.87% · Measure score 1.65 · Achievement 0.69 · Improvement 1.65
Adjusted total nurse staffing
1.05
Baseline 2.07 hours · Performance 2.65 hours · Measure score 1.05 · Achievement 0 · Improvement 1.05
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.72% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 35 · Observed rate 11.43% · Lower 95% interval 6.74% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.3 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 96.77% |
95.27%
1.5 pts better
|
Numerator 30 · Denominator 31 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 31 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 6.45% |
2.29%
4.2 pts worse
|
Numerator 2 · Denominator 31 · Adjusted rate 6.46% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 11.28% |
8.2%
3.1 pts better
|
Numerator 15 · Denominator 133 |
| Staff flu vaccination coverage | 9.93% |
42%
32.1 pts worse
|
Numerator 15 · Denominator 151 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 9 · 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 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 28% |
25.2%
2.8 pts better
|
Numerator 7 · Denominator 25 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.0
0.3 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.5 · Expected 2.0 · 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 2.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
89.6%
9.3 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 97.2% · Q3 100.0% · Q4 100.0% · 4Q avg 98.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.1% |
91.6%
7.5 pts better
|
95.5%
3.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
3.3%
2 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.8% · Q3 1.8% · Q4 0.8% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 93.7% |
50.3%
43.4 pts worse
|
11.4%
82.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 96.9% · Q3 90.6% · Q4 90.4% · 4Q avg 93.7% |
| Percentage of long-stay residents who lose too much weight | 2.4% |
6.5%
4.1 pts better
|
5.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.1% · Q3 0.0% · Q4 3.3% · 4Q avg 2.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 2.6% |
18.5%
15.9 pts better
|
19.6%
17 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.0% · Q3 2.8% · Q4 1.6% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 33.9% |
22.8%
11.1 pts worse
|
16.7%
17.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.8% · Q2 27.9% · Q3 32.4% · Q4 45.5% · 4Q avg 33.9% · 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 | 3.4% |
17.2%
13.8 pts better
|
16.3%
12.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 3.2% · Q3 0.0% · Q4 4.1% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.4% |
15.0%
10.6 pts better
|
14.9%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 5.2% · Q3 3.9% · Q4 4.2% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
1.1%
0.5 pts worse
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 3.7% · Q3 1.4% · Q4 0.6% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.8% |
21.3%
13.5 pts better
|
19.8%
12 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 9.9% · Q3 6.9% · Q4 9.6% · 4Q avg 7.8% |
| Percentage of long-stay residents with pressure ulcers | 5.6% |
5.2%
0.4 pts worse
|
5.1%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 5.2% · Q3 6.9% · Q4 7.0% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.3% |
68.8%
24.5 pts better
|
81.7%
11.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 83.3% · Q2 95.5% · Q3 96.2% · Q4 95.7% · 4Q avg 93.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.3% |
14.0%
0.7 pts better
|
12.0%
1.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.3% · Observed 16.7% · Expected 14.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.4% |
2.3%
3.1 pts worse
|
1.6%
3.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 5.7% · Q3 7.3% · Q4 0.0% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.1% |
63.0%
34.1 pts better
|
79.7%
17.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.6% |
26.2%
5.6 pts better
|
23.9%
3.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.6% · Observed 23.3% · Expected 27.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-08 · Fire 2023-12-08
17 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-11-04 · Fire 2022-11-04
30 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
2025-01-30
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-02-14
F · Potential for more than minimal harm
2025-01-30
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2025-02-14
F · Potential for more than minimal harm
2025-01-30
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-02-19
F · Potential for more than minimal harm
2025-01-30
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-02-14
F · Potential for more than minimal harm
2022-11-04
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-12-26
F · Potential for more than minimal harm
2022-11-04
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-12-26
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-22
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 2026-02-05
D · Potential for more than minimal harm
2026-01-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-02-05
D · Potential for more than minimal harm
2025-12-29
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 2026-02-05
D · Potential for more than minimal harm
2025-12-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-24
G · Actual harm
2025-10-18
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 2025-10-31
G · Actual harm
2025-10-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-10-31
D · Potential for more than minimal harm
2025-10-18
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 2025-10-31
G · Actual harm
2025-07-25
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-08-12
D · Potential for more than minimal harm
2025-07-25
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-08-12
F · Potential for more than minimal harm
2025-03-28
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-04-08
G · Actual harm
2025-03-04
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 2025-03-21
G · Actual harm
2025-03-04
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 2025-03-21
D · Potential for more than minimal harm
2025-03-04
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 2025-03-21
F · Potential for more than minimal harm
2025-01-30
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 2025-02-14
E · Potential for more than minimal harm
2025-01-30
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 2025-02-14
E · Potential for more than minimal harm
2025-01-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-14
E · Potential for more than minimal harm
2025-01-30
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 2025-02-14
E · Potential for more than minimal harm
2025-01-30
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 2025-02-14
E · Potential for more than minimal harm
2025-01-30
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-02-14
E · Potential for more than minimal harm
2025-01-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-14
E · Potential for more than minimal harm
2025-01-30
F924 · Environmental Deficiencies
Health
Put firmly secured handrails on each side of hallways.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-30
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-30
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 2025-02-14
D · Potential for more than minimal harm
2025-01-30
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-30
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 2025-02-14
D · Potential for more than minimal harm
2025-01-30
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-30
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 2025-02-14
D · Potential for more than minimal harm
2025-01-30
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-30
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-23
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 2025-02-05
F · Potential for more than minimal harm
2024-11-14
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-11-22
E · Potential for more than minimal harm
2024-09-16
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 2024-10-04
D · Potential for more than minimal harm
2024-09-16
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 2024-10-04
F · Potential for more than minimal harm
2024-02-05
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 2024-02-14
D · Potential for more than minimal harm
2024-01-04
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 2024-01-17
F · Potential for more than minimal harm
2023-12-08
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 2023-12-22
F · Potential for more than minimal harm
2023-12-08
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-12-22
E · Potential for more than minimal harm
2023-12-08
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 2024-01-03
D · Potential for more than minimal harm
2023-12-08
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 2024-01-17
D · Potential for more than minimal harm
2023-12-08
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 2024-01-03
D · Potential for more than minimal harm
2023-12-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-03
D · Potential for more than minimal harm
2023-12-08
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 2024-01-03
D · Potential for more than minimal harm
2023-12-08
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-01-03
D · Potential for more than minimal harm
2023-12-08
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 2023-12-22
D · Potential for more than minimal harm
2023-12-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-03
D · Potential for more than minimal harm
2023-12-08
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-01-03
D · Potential for more than minimal harm
2023-12-08
F914 · Environmental Deficiencies
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2023-12-22
C · Minimal harm
2023-12-08
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2023-12-20
F · Potential for more than minimal harm
2023-11-22
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 2023-12-22
F · Potential for more than minimal harm
2023-11-22
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-12-19
F · Potential for more than minimal harm
2023-09-14
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-09-28
E · Potential for more than minimal harm
2023-09-14
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 2023-09-25
D · Potential for more than minimal harm
2023-09-14
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 2023-09-25
D · Potential for more than minimal harm
2023-09-14
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 2023-09-25
G · Actual harm
2023-08-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-08
G · Actual harm
2023-08-17
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-09-08
G · Actual harm
2023-05-30
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 2023-06-21
F · Potential for more than minimal harm
2023-05-30
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 2023-06-21
F · Potential for more than minimal harm
2023-05-30
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-06-21
E · Potential for more than minimal harm
2023-05-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-21
E · Potential for more than minimal harm
2023-05-30
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-06-21
D · Potential for more than minimal harm
2023-05-30
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-06-21
D · Potential for more than minimal harm
2023-05-30
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 2023-06-21
D · Potential for more than minimal harm
2023-05-30
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 2023-06-21
D · Potential for more than minimal harm
2023-03-15
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-03-29
G · Actual harm
2022-11-04
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-11-25
F · Potential for more than minimal harm
2022-11-04
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 2022-11-25
E · Potential for more than minimal harm
2022-11-04
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 2022-11-25
E · Potential for more than minimal harm
2022-11-04
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 2022-11-25
E · Potential for more than minimal harm
2022-11-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-25
D · Potential for more than minimal harm
2022-11-04
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-11-25
D · Potential for more than minimal harm
2022-11-04
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-11-25
D · Potential for more than minimal harm
2022-11-04
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 2022-11-25
D · Potential for more than minimal harm
2022-11-04
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 2022-11-25
D · Potential for more than minimal harm
2022-11-04
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 2022-11-25
D · Potential for more than minimal harm
2022-11-04
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 2022-11-25
Penalties and ownership
What sits behind the stars
$38,800
2025-07-25
Fine
Fine · fine $38,800
Fine
$0
2025-01-23
Payment Denial
Payment Denial · denial start 2025-03-28 · 11 days
11 day denial
$149,538
2023-08-17
Fine
Fine · fine $149,538
Fine
$0
2023-08-17
Payment Denial
Payment Denial · denial start 2023-09-15 · 13 days
13 day denial
$46,449
2023-05-30
Fine
Fine · fine $46,449
Fine
Ownership
Avenue Associates LLC
5% Or Greater Mortgage Interest · Organization
Desai, Manish
Operational/Managerial Control · Individual
Elkaim, Daniel
Operational/Managerial Control · Individual
Lipshitz, Rita
5% Or Greater Direct Ownership Interest · Individual
Mashiach, Rhonda
5% Or Greater Direct Ownership Interest · Individual
Mashiach, Yaacov
5% Or Greater Direct Ownership Interest · Individual
Mashiach, Yaacov
Operational/Managerial Control · Individual
Mashiach, Yaacov
Corporate Officer · Individual
Mashiach, Yechiel
5% Or Greater Direct Ownership Interest · Individual
Mashiach, Yechiel
Operational/Managerial Control · Individual
Mashiach, Yechiel
Corporate Officer · Individual
Nathan And Shirley Rothner Family Trust
5% Or Greater Direct Ownership Interest · Organization
Sepessy, Laura
Operational/Managerial Control · Individual
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