Cycle 1
Health 2025-01-21 · Fire 2025-01-21
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
17 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Libertyville, IL
Libertyville Manor Ext Care
2-star overall rating with 1-star inspections with $246,461 in total fines with 10 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
610 Peterson Road, Libertyville, IL
(847) 367-6100
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
174
Certified beds
Average residents
27
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1978-04-01
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
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.32% |
10.72%
2.6 pts worse
|
No Different than the National Rate · Eligible stays 66 · Observed rate 19.7% · Lower 95% interval 9.04% |
| Discharge to community | 47.52% |
50.57%
3 pts worse
|
No Different than the National Rate · Eligible stays 57 · Observed rate 40.35% · Lower 95% interval 35.7% |
| Medicare spending per beneficiary | 0.75 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 36 · Denominator 36 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 36 |
| Discharge self-care score | 73.08% |
53.69%
19.4 pts better
|
Numerator 19 · Denominator 26 |
| Discharge mobility score | 73.08% |
50.94%
22.1 pts better
|
Numerator 19 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 36 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.62% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 26 · Observed rate 3.85% · Lower 95% interval 3.38% |
| Staff COVID-19 vaccination coverage | 7.78% |
8.2%
0.4 pts worse
|
Numerator 7 · Denominator 90 |
| Staff flu vaccination coverage | 40% |
42%
2 pts worse
|
Numerator 48 · Denominator 120 |
| Discharge function score | 61.54% |
56.45%
5.1 pts better
|
Numerator 16 · Denominator 26 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 62.5% |
96.28%
33.8 pts worse
|
Numerator 15 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.6%
10.4 pts better
|
93.4%
6.6 pts better
|
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 assessed and appropriately given the seasonal influenza vaccine | 4.2% |
91.6%
87.4 pts worse
|
95.5%
91.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 4.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
3.3%
0.4 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 7.1% · Q4 4.3% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
50.3%
49.3 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 10.5% |
6.5%
4 pts worse
|
5.4%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q3 8.3% · Q4 5.0% · 4Q avg 10.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 59.3% |
18.5%
40.8 pts worse
|
19.6%
39.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 65.2% · Q3 58.3% · Q4 60.0% · 4Q avg 59.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.7% |
22.8%
15.1 pts better
|
16.7%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.7% · 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 | 6.8% |
17.2%
10.4 pts better
|
16.3%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.9% |
15.0%
2.1 pts better
|
14.9%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.8% |
1.1%
2.7 pts worse
|
1.0%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 4.3% · Q3 3.0% · Q4 4.3% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 16.7% |
1.7%
15 pts worse
|
1.7%
15 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 16.7% · Q3 10.7% · Q4 13.0% · 4Q avg 16.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.4% |
21.3%
13.9 pts better
|
19.8%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 13.9% · Q3 7.4% · Q4 0.0% · 4Q avg 7.4% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
5.2%
5.2 pts better
|
5.1%
5.1 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 short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
68.8%
31.2 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 100.0% · Q3 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.7% |
14.0%
7.3 pts better
|
12.0%
5.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.7% · Observed 6.9% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.3%
2.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 26.9% |
63.0%
36.1 pts worse
|
79.7%
52.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 26.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.7% |
26.2%
4.5 pts better
|
23.9%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.7% · Observed 24.1% · Expected 26.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-08 · Fire 2024-02-08
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
23 fire-safety deficiencies
Top issue: Emergency Preparedness (9 deficiencies)
Cycle 3
Health 2023-03-22 · Fire 2023-03-22
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
26 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-21
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-02-06
F · Potential for more than minimal harm
2025-01-21
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-02-04
F · Potential for more than minimal harm
2025-01-21
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-03-31
F · Potential for more than minimal harm
2025-01-21
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-02-06
F · Potential for more than minimal harm
2025-01-21
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 2025-06-16
F · Potential for more than minimal harm
2025-01-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-03
F · Potential for more than minimal harm
2025-01-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-04
F · Potential for more than minimal harm
2025-01-21
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-03-28
F · Potential for more than minimal harm
2025-01-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-02-12
F · Potential for more than minimal harm
2025-01-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-13
F · Potential for more than minimal harm
2025-01-21
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 2025-02-12
E · Potential for more than minimal harm
2025-01-21
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 2025-02-10
E · Potential for more than minimal harm
2025-01-21
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-01-30
E · Potential for more than minimal harm
2025-01-21
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-02-03
E · Potential for more than minimal harm
2025-01-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-21
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 2025-01-28
D · Potential for more than minimal harm
2025-01-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-30
F · Potential for more than minimal harm
2024-02-08
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-04-30
F · Potential for more than minimal harm
2024-02-08
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-04-30
F · Potential for more than minimal harm
2024-02-08
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2024-03-21
F · Potential for more than minimal harm
2024-02-08
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2024-04-30
F · Potential for more than minimal harm
2024-02-08
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-04-30
F · Potential for more than minimal harm
2024-02-08
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2024-04-30
F · Potential for more than minimal harm
2024-02-08
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-04-30
F · Potential for more than minimal harm
2024-02-08
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-04-30
F · Potential for more than minimal harm
2024-02-08
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-03-21
F · Potential for more than minimal harm
2024-02-08
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-04-30
F · Potential for more than minimal harm
2024-02-08
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-04-30
F · Potential for more than minimal harm
2024-02-08
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-03-21
F · Potential for more than minimal harm
2024-02-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-30
F · Potential for more than minimal harm
2024-02-08
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-03-21
F · Potential for more than minimal harm
2024-02-08
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-04-30
F · Potential for more than minimal harm
2024-02-08
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-03-31
F · Potential for more than minimal harm
2024-02-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-28
F · Potential for more than minimal harm
2024-02-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-30
E · Potential for more than minimal harm
2024-02-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-04-30
E · Potential for more than minimal harm
2024-02-08
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 2024-04-30
E · Potential for more than minimal harm
2024-02-08
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-04-30
E · Potential for more than minimal harm
2024-02-08
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 2024-04-30
E · Potential for more than minimal harm
2024-02-08
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-04-30
F · Potential for more than minimal harm
2023-03-22
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-03-22
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-03-22
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2023-05-29
F · Potential for more than minimal harm
2023-03-22
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-03-22
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-03-22
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-05-29
F · Potential for more than minimal harm
2023-03-22
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-05-29
F · Potential for more than minimal harm
2023-03-22
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-05-29
F · Potential for more than minimal harm
2023-03-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-03-22
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-03-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-29
F · Potential for more than minimal harm
2023-03-22
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-03-22
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-05-29
F · Potential for more than minimal harm
2023-03-22
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-07-14
F · Potential for more than minimal harm
2023-03-22
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-03-28
F · Potential for more than minimal harm
2023-03-22
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-03-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-29
F · Potential for more than minimal harm
2023-03-22
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-03-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-05-29
F · Potential for more than minimal harm
2023-03-22
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-05-29
F · Potential for more than minimal harm
2023-03-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-31
F · Potential for more than minimal harm
2023-03-22
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 2023-05-29
E · Potential for more than minimal harm
2023-03-22
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 2023-05-29
E · Potential for more than minimal harm
2023-03-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-29
E · Potential for more than minimal harm
2023-03-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-04-14
E · Potential for more than minimal harm
2023-03-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-05-29
Inspection history
Recent health citations
G · Actual harm
2025-02-18
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 2025-03-21
K · Immediate jeopardy
2025-01-21
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-01-21
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 2025-02-28
F · Potential for more than minimal harm
2025-01-21
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 2025-02-28
E · Potential for more than minimal harm
2025-01-21
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
E · Potential for more than minimal harm
2025-01-21
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 2025-04-25
E · Potential for more than minimal harm
2025-01-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-21
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-21
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 2025-02-28
D · Potential for more than minimal harm
2025-01-21
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 2025-02-28
D · Potential for more than minimal harm
2025-01-21
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-04-25
D · Potential for more than minimal harm
2024-12-09
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-12-31
D · Potential for more than minimal harm
2024-04-17
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-06-03
G · Actual harm
2024-02-08
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-03-31
F · Potential for more than minimal harm
2024-02-08
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 2024-03-31
F · Potential for more than minimal harm
2024-02-08
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-04-11
F · Potential for more than minimal harm
2024-02-08
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-03-31
F · Potential for more than minimal harm
2024-02-08
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-02-08
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-03-31
D · Potential for more than minimal harm
2024-02-08
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 2024-05-10
J · Immediate jeopardy
2023-10-20
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 2023-10-21
F · Potential for more than minimal harm
2023-10-20
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-11-30
F · Potential for more than minimal harm
2023-03-22
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-22
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 2023-04-28
D · Potential for more than minimal harm
2023-03-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-22
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 2023-04-28
D · Potential for more than minimal harm
2023-03-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-28
Penalties and ownership
What sits behind the stars
$121,304
2024-02-08
Fine
Fine · fine $121,304
Fine
$0
2024-02-08
Payment Denial
Payment Denial · denial start 2024-03-02 · 93 days
93 day denial
$125,157
2023-10-20
Fine
Fine · fine $125,157
Fine
$0
2023-10-20
Payment Denial
Payment Denial · denial start 2023-11-09 · 21 days
21 day denial
Ownership
Stokovich, Milan
5% Or Greater Direct Ownership Interest · Individual
Stokovich, Milan
Corporate Officer · Individual
Stokovich, Milan
W-2 Managing Employee · Individual
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