Cycle 1
Health 2025-02-28 · Fire 2025-02-28
24 health deficiencies
Top issue: Quality of Life and Care (12 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Berwyn, IL
Nexus at Berwyn
1-star overall rating with 1-star inspections with abuse icon flag with $231,957 in total fines with 24 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
3601 South Harlem Avenue, Berwyn, IL
(708) 749-4160
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
145
Certified beds
Average residents
130
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Legacy Healthcare
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
90 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.41
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.07
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.72
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.20
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.48
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
2.69
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
2.55
CMS adjusted total nurse staffing hours
Case-mix index
1.71
Higher values indicate more complex resident acuity
RN turnover
84%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
68%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,667
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
1.96
Composite VBP score used to determine payment impact.
Payment multiplier
0.9804
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.79
Baseline 22.16% · Performance 21.50% · Measure score 0.79 · Achievement 0 · Improvement 0.79
Healthcare-associated infections
0
Baseline 8.38% · Performance 8.84% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 64.47% · Performance 69.17% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 2.73 hours · Performance 2.79 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.78% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 70 · Observed rate 17.14% · Lower 95% interval 8.12% |
| Discharge to community | 42.94% |
50.57%
7.6 pts worse
|
No Different than the National Rate · Eligible stays 52 · Observed rate 28.85% · Lower 95% interval 29.71% |
| Medicare spending per beneficiary | 1.15 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.04% |
95.27%
2.8 pts better
|
Numerator 50 · Denominator 51 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 51 |
| Discharge self-care score | 13.04% |
53.69%
40.6 pts worse
|
Numerator 3 · Denominator 23 |
| Discharge mobility score | 17.39% |
50.94%
33.5 pts worse
|
Numerator 4 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 5.88% |
2.29%
3.6 pts worse
|
Numerator 3 · Denominator 51 · Adjusted rate 4.48% |
| Healthcare-associated infections requiring hospitalization | 8.84% |
7.12%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 30 · Observed rate 20% · Lower 95% interval 4.31% |
| Staff COVID-19 vaccination coverage | 10.3% |
8.2%
2.1 pts better
|
Numerator 17 · Denominator 165 |
| Staff flu vaccination coverage | 92.36% |
42%
50.4 pts better
|
Numerator 145 · Denominator 157 |
| Discharge function score | 21.74% |
56.45%
34.7 pts worse
|
Numerator 5 · Denominator 23 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 26 · Denominator 26 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 18.18% |
25.2%
7 pts worse
|
Numerator 4 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.0 |
2.0
1 pts worse
|
1.9
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 4.8 · Expected 3.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
2.3
1.5 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 1.0 · Expected 2.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 78.0% |
89.6%
11.6 pts worse
|
93.4%
15.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 50.9% · Q2 79.3% · Q3 95.7% · Q4 84.7% · 4Q avg 78.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 84.3% |
91.6%
7.3 pts worse
|
95.5%
11.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 84.3% |
| 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 1.8% · Q2 0.9% · Q3 0.9% · Q4 1.7% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 99.2% |
50.3%
48.9 pts worse
|
11.4%
87.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 98.9% · Q3 100.0% · Q4 99.0% · 4Q avg 99.2% |
| Percentage of long-stay residents who lose too much weight | 3.1% |
6.5%
3.4 pts better
|
5.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.6% · Q3 3.7% · Q4 3.7% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.5% |
18.5%
10 pts better
|
19.6%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 10.0% · Q3 6.3% · Q4 8.0% · 4Q avg 8.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.1% |
22.8%
2.7 pts better
|
16.7%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 18.3% · Q3 26.0% · Q4 17.4% · 4Q avg 20.1% · 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 | 21.5% |
17.2%
4.3 pts worse
|
16.3%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 35.6% · Q3 21.8% · Q4 14.8% · 4Q avg 21.5% · 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 6.5% · Q2 17.7% · Q3 13.3% · Q4 5.2% · 4Q avg 10.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
1.1%
0.3 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.4% · Q3 0.7% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.7%
1.3 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.9% · Q4 0.9% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.4% |
21.3%
4.1 pts worse
|
19.8%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 19.9% · Q3 29.9% · Q4 25.2% · 4Q avg 25.4% |
| Percentage of long-stay residents with pressure ulcers | 7.4% |
5.2%
2.2 pts worse
|
5.1%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 8.0% · Q3 4.9% · Q4 6.1% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 40.3% |
68.8%
28.5 pts worse
|
81.7%
41.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 44.1% · Q3 48.1% · Q4 49.3% · 4Q avg 40.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.3% |
14.0%
3.7 pts better
|
12.0%
1.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.3% · Observed 14.6% · Expected 15.8% · 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 · 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 who were assessed and appropriately given the seasonal influenza vaccine | 49.3% |
63.0%
13.7 pts worse
|
79.7%
30.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 49.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.8% |
26.2%
4.6 pts worse
|
23.9%
6.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.8% · Observed 52.1% · Expected 40.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-25 · Fire 2024-04-25
21 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Cycle 3
Health 2022-12-02 · Fire 2022-12-02
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-28
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2025-03-05
F · Potential for more than minimal harm
2025-02-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-19
F · Potential for more than minimal harm
2025-02-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-05
F · Potential for more than minimal harm
2025-02-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-19
E · Potential for more than minimal harm
2025-02-28
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-03-05
E · Potential for more than minimal harm
2025-02-28
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2025-03-05
E · Potential for more than minimal harm
2025-02-28
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-03-05
E · Potential for more than minimal harm
2025-02-28
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 2025-03-05
E · Potential for more than minimal harm
2025-02-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-21
E · Potential for more than minimal harm
2025-02-28
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2025-03-05
E · Potential for more than minimal harm
2025-02-28
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-03-05
E · Potential for more than minimal harm
2025-02-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-05
E · Potential for more than minimal harm
2025-02-28
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2025-03-05
E · Potential for more than minimal harm
2025-02-28
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-03-05
E · Potential for more than minimal harm
2025-02-28
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-03-05
E · Potential for more than minimal harm
2025-02-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-05
F · Potential for more than minimal harm
2024-04-25
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-05-02
F · Potential for more than minimal harm
2024-04-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-02
F · Potential for more than minimal harm
2024-04-25
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-06-05
F · Potential for more than minimal harm
2024-04-25
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-05-02
F · Potential for more than minimal harm
2024-04-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-02
F · Potential for more than minimal harm
2024-04-25
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2025-03-04
E · Potential for more than minimal harm
2024-04-25
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 2024-05-02
E · Potential for more than minimal harm
2024-04-25
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-05-02
E · Potential for more than minimal harm
2024-04-25
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 2024-05-02
E · Potential for more than minimal harm
2024-04-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-06-05
E · Potential for more than minimal harm
2024-04-25
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-07-08
E · Potential for more than minimal harm
2024-04-25
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-07-01
E · Potential for more than minimal harm
2024-04-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-02
E · Potential for more than minimal harm
2024-04-25
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-05-02
E · Potential for more than minimal harm
2024-04-25
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-05-02
D · Potential for more than minimal harm
2024-04-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-02
F · Potential for more than minimal harm
2022-12-02
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2022-12-22
F · Potential for more than minimal harm
2022-12-02
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-12-22
F · Potential for more than minimal harm
2022-12-02
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-12-22
F · Potential for more than minimal harm
2022-12-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-22
F · Potential for more than minimal harm
2022-12-02
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-12-22
F · Potential for more than minimal harm
2022-12-02
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-12-22
E · Potential for more than minimal harm
2022-12-02
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 2022-12-22
E · Potential for more than minimal harm
2022-12-02
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2022-12-22
E · Potential for more than minimal harm
2022-12-02
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-12-22
E · Potential for more than minimal harm
2022-12-02
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2022-12-22
E · Potential for more than minimal harm
2022-12-02
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 2022-12-22
E · Potential for more than minimal harm
2022-12-02
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-12-22
E · Potential for more than minimal harm
2022-12-02
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2022-12-22
E · Potential for more than minimal harm
2022-12-02
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-12-22
E · Potential for more than minimal harm
2022-12-02
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2022-12-22
E · Potential for more than minimal harm
2022-12-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-12-22
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-30
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 2026-01-31
D · Potential for more than minimal harm
2026-01-30
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2026-01-31
D · Potential for more than minimal harm
2026-01-30
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 2026-01-31
D · Potential for more than minimal harm
2026-01-30
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2026-01-31
D · Potential for more than minimal harm
2026-01-30
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 2026-01-31
J · Immediate jeopardy
2025-12-30
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 2025-12-31
E · Potential for more than minimal harm
2025-12-22
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 2025-12-23
G · Actual harm
2025-12-12
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 2025-12-13
D · Potential for more than minimal harm
2025-12-12
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-12-13
E · Potential for more than minimal harm
2025-09-30
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 2025-10-03
D · Potential for more than minimal harm
2025-09-11
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 2025-09-12
G · Actual harm
2025-07-01
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-07-02
D · Potential for more than minimal harm
2025-07-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-02
E · Potential for more than minimal harm
2025-06-09
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 2025-06-10
D · Potential for more than minimal harm
2025-06-09
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 2025-06-10
G · Actual harm
2025-04-17
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 2025-04-18
D · Potential for more than minimal harm
2025-03-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-24
E · Potential for more than minimal harm
2025-02-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-03
D · Potential for more than minimal harm
2025-02-28
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-03-03
D · Potential for more than minimal harm
2025-02-28
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 2025-03-03
D · Potential for more than minimal harm
2025-02-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-03
D · Potential for more than minimal harm
2025-02-28
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 2025-03-03
D · Potential for more than minimal harm
2025-02-28
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 2025-03-03
D · Potential for more than minimal harm
2025-02-28
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-03-03
G · Actual harm
2025-01-22
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 2025-01-23
D · Potential for more than minimal harm
2025-01-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-12-23
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2024-12-24
D · Potential for more than minimal harm
2024-09-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-20
D · Potential for more than minimal harm
2024-09-13
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 2024-09-20
G · Actual harm
2024-07-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-22
G · Actual harm
2024-07-08
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 2024-07-22
D · Potential for more than minimal harm
2024-07-08
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-07-22
D · Potential for more than minimal harm
2024-07-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-22
F · Potential for more than minimal harm
2024-04-25
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 2024-05-07
E · Potential for more than minimal harm
2024-04-25
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-05-07
E · Potential for more than minimal harm
2024-04-25
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 2024-05-07
E · Potential for more than minimal harm
2024-04-25
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 2024-05-07
E · Potential for more than minimal harm
2024-04-25
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-05-07
E · Potential for more than minimal harm
2024-04-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-07
D · Potential for more than minimal harm
2024-04-25
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-05-07
D · Potential for more than minimal harm
2024-04-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-05-07
D · Potential for more than minimal harm
2024-04-25
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 2024-05-07
G · Actual harm
2024-04-12
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 2024-04-19
D · Potential for more than minimal harm
2024-04-12
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 2024-04-19
D · Potential for more than minimal harm
2024-04-12
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 2024-04-19
G · Actual harm
2023-05-30
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 2023-06-14
D · Potential for more than minimal harm
2023-05-30
F620 · Resident Rights Deficiencies
Health
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
Corrected 2023-06-14
D · Potential for more than minimal harm
2023-05-30
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2023-06-14
D · Potential for more than minimal 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 2023-06-14
D · Potential for more than minimal harm
2022-12-02
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-12-02
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 2022-12-14
D · Potential for more than minimal harm
2022-12-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-12-02
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 2022-12-14
D · Potential for more than minimal harm
2022-12-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-12-02
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 2022-12-14
Penalties and ownership
What sits behind the stars
$17,460
2025-07-01
Fine
Fine · fine $17,460
Fine
$12,425
2025-01-16
Fine
Fine · fine $12,425
Fine
$140,530
2024-04-12
Fine
Fine · fine $140,530
Fine
$0
2024-04-12
Payment Denial
Payment Denial · denial start 2024-05-09 · 74 days
74 day denial
$61,542
2023-05-30
Fine
Fine · fine $61,542
Fine
Ownership
Chaim Rajchenbach Descendants Tr Ua 04282008
5% Or Greater Direct Ownership Interest · Organization
Doros Generation Trust U/A/D 1/3/12
5% Or Greater Direct Ownership Interest · Organization
Legacy Healthcare Financial Services LLC
Operational/Managerial Control · Organization
Rajchenbach, Chaim
Corporate Officer · Individual
Seifer, Gianni
W-2 Managing Employee · Individual
Shabat, Menachem
Corporate Officer · Individual
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#3
City View Multicare Center
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0-star overall rating with 0-star inspections with Special Focus status with $248,798 in total fines with 24 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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