Cycle 1
Health 2025-07-25 · Fire 2025-07-25
16 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
La Grange, IL
Meadowbrook Manor - Lagrange
2-star overall rating with 2-star inspections with $56,831 in total fines with 16 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
339 9th Avenue, La Grange, IL
(708) 354-4660
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
197
Certified beds
Average residents
130
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2005-10-31
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
0.97
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.81
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.30
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
4.07
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.77
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.33
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.70
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.76
CMS adjusted RN staffing hours
Adjusted total hours
3.21
CMS adjusted total nurse staffing hours
Case-mix index
1.73
Higher values indicate more complex resident acuity
RN turnover
54%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,944
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
9.48
Composite VBP score used to determine payment impact.
Payment multiplier
0.9808
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.24% · Performance 23.15% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 8.13% · Performance 8.84% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.98
Baseline 56.03% · Performance 51.50% · Measure score 2.98 · Achievement 2.98 · Improvement 0.95
Adjusted total nurse staffing
0.81
Baseline 2.26 hours · Performance 2.72 hours · Measure score 0.81 · Achievement 0 · Improvement 0.81
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.57% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 584 · Observed rate 11.64% · Lower 95% interval 8.76% |
| Discharge to community | 60.52% |
50.57%
10 pts better
|
Better than the National Rate · Eligible stays 689 · Observed rate 48.62% · Lower 95% interval 55.83% |
| Medicare spending per beneficiary | 1.21 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 94.72% |
95.27%
0.5 pts worse
|
Numerator 377 · Denominator 398 |
| Falls with major injury | 2.01% |
0.77%
1.2 pts worse
|
Numerator 8 · Denominator 398 |
| Discharge self-care score | 49.8% |
53.69%
3.9 pts worse
|
Numerator 123 · Denominator 247 |
| Discharge mobility score | 38.06% |
50.94%
12.9 pts worse
|
Numerator 94 · Denominator 247 |
| Pressure ulcers or injuries, new or worsened | 5.03% |
2.29%
2.7 pts worse
|
Numerator 20 · Denominator 398 · Adjusted rate 4.49% |
| Healthcare-associated infections requiring hospitalization | 8.84% |
7.12%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 414 · Observed rate 9.9% · Lower 95% interval 6.68% |
| Staff COVID-19 vaccination coverage | 8.05% |
8.2%
0.1 pts worse
|
Numerator 21 · Denominator 261 |
| Staff flu vaccination coverage | 22.71% |
42%
19.3 pts worse
|
Numerator 47 · Denominator 207 |
| Discharge function score | 36.03% |
56.45%
20.4 pts worse
|
Numerator 89 · Denominator 247 |
| Transfer of health information to provider | 99.58% |
95.95%
3.6 pts better
|
Numerator 239 · Denominator 240 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 105 · Denominator 105 |
| Resident COVID-19 vaccinations up to date | 43.9% |
25.2%
18.7 pts better
|
Numerator 90 · Denominator 205 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.0
0.4 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 2.0 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.3
0.9 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.4 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.5% |
89.6%
6.9 pts better
|
93.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 95.0% · Q3 94.9% · Q4 96.9% · 4Q avg 96.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.8% |
91.6%
2.2 pts better
|
95.5%
1.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.8% |
3.3%
3.5 pts worse
|
3.3%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 7.9% · Q3 8.1% · Q4 3.1% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 89.4% |
50.3%
39.1 pts worse
|
11.4%
78 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 72.0% · Q4 86.7% · 4Q avg 89.4% |
| Percentage of long-stay residents who lose too much weight | 7.4% |
6.5%
0.9 pts worse
|
5.4%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 5.8% · Q3 8.4% · Q4 4.7% · 4Q avg 7.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.6% |
18.5%
10.9 pts better
|
19.6%
12 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 7.7% · Q3 8.0% · Q4 6.8% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.5% |
22.8%
7.3 pts better
|
16.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 14.1% · Q3 15.6% · Q4 21.1% · 4Q avg 15.5% · 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 | 26.7% |
17.2%
9.5 pts worse
|
16.3%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 45.9% · 4Q avg 26.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.4% |
15.0%
3.4 pts worse
|
14.9%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 21.0% · Q3 17.3% · Q4 18.2% · 4Q avg 18.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.1%
0.8 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.6% · Q3 0.0% · Q4 0.6% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.7%
1.4 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.2% |
21.3%
5.9 pts worse
|
19.8%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.5% · Q2 23.4% · Q3 30.3% · Q4 32.9% · 4Q avg 27.2% |
| Percentage of long-stay residents with pressure ulcers | 9.1% |
5.2%
3.9 pts worse
|
5.1%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 9.4% · Q3 10.6% · Q4 6.5% · 4Q avg 9.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.3% |
68.8%
17.5 pts better
|
81.7%
4.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.3% · Q2 90.2% · Q3 81.2% · Q4 73.2% · 4Q avg 86.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.6% |
14.0%
3.4 pts better
|
12.0%
1.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.6% · Observed 11.0% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
2.3%
0.8 pts better
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.1% · Q3 0.4% · Q4 2.7% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.4% |
63.0%
23.4 pts better
|
79.7%
6.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.2% |
26.2%
3 pts worse
|
23.9%
5.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.2% · Observed 33.1% · Expected 27.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-06 · Fire 2024-06-06
18 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
13 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Cycle 3
Health 2023-05-24 · Fire 2023-05-24
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-29
F · Potential for more than minimal harm
2025-07-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-08-29
E · Potential for more than minimal harm
2025-07-25
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-08-29
E · Potential for more than minimal harm
2025-07-25
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-08-29
E · Potential for more than minimal harm
2025-07-25
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-08-29
E · Potential for more than minimal harm
2025-07-25
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-08-29
E · Potential for more than minimal harm
2025-07-25
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-08-29
E · Potential for more than minimal harm
2025-07-25
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-08-29
E · Potential for more than minimal harm
2025-07-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-08-29
E · Potential for more than minimal harm
2025-07-25
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-08-29
E · Potential for more than minimal harm
2025-07-25
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-07-25
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 2025-08-29
D · Potential for more than minimal harm
2025-07-25
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-08-29
F · Potential for more than minimal harm
2024-06-06
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-06-28
F · Potential for more than minimal harm
2024-06-06
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-07-22
F · Potential for more than minimal harm
2024-06-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-08
F · Potential for more than minimal harm
2024-06-06
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-06-28
F · Potential for more than minimal harm
2024-06-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-28
F · Potential for more than minimal harm
2024-06-06
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2024-06-28
E · Potential for more than minimal harm
2024-06-06
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-06-28
E · Potential for more than minimal harm
2024-06-06
K254 · Egress Deficiencies
Fire Safety
Provide hallway or ground-level exits in all residents' rooms.
Corrected 2024-06-28
E · Potential for more than minimal harm
2024-06-06
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-06-28
E · Potential for more than minimal harm
2024-06-06
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-08-09
E · Potential for more than minimal harm
2024-06-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-28
E · Potential for more than minimal harm
2024-06-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-28
E · Potential for more than minimal harm
2024-06-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-07-08
F · Potential for more than minimal harm
2023-05-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-07-19
F · Potential for more than minimal harm
2023-05-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-19
F · Potential for more than minimal harm
2023-05-24
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-07-19
F · Potential for more than minimal harm
2023-05-24
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-05-24
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 2023-06-16
E · Potential for more than minimal harm
2023-05-24
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-05-24
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-05-24
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-05-24
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-05-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-05-24
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-05-24
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 2023-06-16
E · Potential for more than minimal harm
2023-05-24
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-05-24
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 2023-06-16
D · Potential for more than minimal harm
2023-05-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-29
D · Potential for more than minimal harm
2025-09-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-25
F · Potential for more than minimal harm
2025-07-25
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 2025-08-05
E · Potential for more than minimal harm
2025-07-25
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-08-05
E · Potential for more than minimal harm
2025-07-25
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 2025-08-05
E · Potential for more than minimal harm
2025-07-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-05
E · Potential for more than minimal harm
2025-07-25
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-08-05
D · Potential for more than minimal harm
2025-07-25
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 2025-08-05
D · Potential for more than minimal harm
2025-07-25
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 2025-08-05
D · Potential for more than minimal harm
2025-07-25
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 2025-08-05
D · Potential for more than minimal harm
2025-07-25
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 2025-08-05
D · Potential for more than minimal harm
2025-07-25
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 2025-08-05
D · Potential for more than minimal harm
2025-07-25
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 2025-08-05
E · Potential for more than minimal harm
2025-06-07
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 2025-06-13
D · Potential for more than minimal harm
2025-06-07
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 2025-06-13
D · Potential for more than minimal harm
2025-05-07
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-05-08
J · Immediate jeopardy
2025-01-13
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 2025-01-14
G · Actual harm
2024-12-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-23
G · Actual harm
2024-10-25
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 2024-11-07
E · Potential for more than minimal harm
2024-07-28
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-08-11
D · Potential for more than minimal harm
2024-07-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-11
D · Potential for more than minimal harm
2024-07-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-11
D · Potential for more than minimal harm
2024-07-28
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-08-11
D · Potential for more than minimal harm
2024-07-28
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 2024-08-11
D · Potential for more than minimal harm
2024-06-27
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 2024-07-10
E · Potential for more than minimal harm
2024-06-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-06-06
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 2024-06-28
D · Potential for more than minimal harm
2024-06-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-06-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-06-06
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 2024-06-28
D · Potential for more than minimal harm
2024-06-06
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 2024-06-28
D · Potential for more than minimal harm
2024-06-06
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-06-06
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-06-06
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 2024-06-28
G · Actual harm
2023-11-20
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 2023-12-15
F · Potential for more than minimal harm
2023-09-22
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-05-24
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 2023-06-11
D · Potential for more than minimal harm
2023-05-24
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-06-11
D · Potential for more than minimal harm
2023-05-24
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 2023-06-11
D · Potential for more than minimal harm
2023-05-24
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 2023-06-11
D · Potential for more than minimal harm
2023-05-24
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 2023-06-11
D · Potential for more than minimal harm
2023-05-24
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 2023-06-11
D · Potential for more than minimal harm
2023-05-24
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-06-11
D · Potential for more than minimal harm
2023-05-24
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 2023-06-11
G · Actual harm
2023-03-19
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 2023-03-31
Penalties and ownership
What sits behind the stars
$36,453
2025-01-13
Fine
Fine · fine $36,453
Fine
$20,378
2024-12-09
Fine
Fine · fine $20,378
Fine
Ownership
Jafari Family LLC
5% Or Greater Direct Ownership Interest · Organization
Rbj Investments LP
5% Or Greater Direct Ownership Interest · Organization
Louis William Dimas Family Limited Partnership
5% Or Greater Direct Ownership Interest · Organization
Vangel, Dorothy
5% Or Greater Direct Ownership Interest · Individual
Vangel, Nicholas
5% Or Greater Direct Ownership Interest · Individual
Chris Vangel Gst Exempt Descendants Trust
5% Or Greater Direct Ownership Interest · Organization
Katherine Hocuk Gst Exempt Descendants Trust
5% Or Greater Direct Ownership Interest · Organization
Jafari, Kianoosh
Corporate Director · Individual
Vangel, Christopher
Corporate Director · Individual
Vangel, Christopher
Contracted Managing Employee · Individual
Vangel, Nicholas
Corporate Director · Individual
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