Cycle 1
Health 2024-12-19 · Fire 2024-12-19
14 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
17 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Oak Lawn, IL
Oak Lawn Respiratory & Rehab
1-star overall rating with 2-star inspections with $307,053 in total fines with 14 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
9525 South Mayfield, Oak Lawn, IL
(708) 636-7000
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
143
Certified beds
Average residents
72
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Infinity Healthcare Consulting
Operator or chain grouping
Approved since
1997-07-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
70 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 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
0.63
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.47
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.77
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
2.86
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.10
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
2.60
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.61
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.43
CMS adjusted RN staffing hours
Adjusted total hours
1.96
CMS adjusted total nurse staffing hours
Case-mix index
2.00
Higher values indicate more complex resident acuity
RN turnover
94%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
76%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,452
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
5.06
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
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
0
Baseline 50.00% · Performance 75.47% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.01
Baseline 1.95 hours · Performance 2.53 hours · Measure score 1.01 · Achievement 0 · Improvement 1.01
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| 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 | 1.39 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 92.68% |
95.27%
2.6 pts worse
|
Numerator 38 · Denominator 41 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 41 |
| 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 | 2.44% |
2.29%
0.1 pts worse
|
Numerator 1 · Denominator 41 · Adjusted rate 2% |
| 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 | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 65 |
| Staff flu vaccination coverage | 6.15% |
42%
35.9 pts worse
|
Numerator 4 · Denominator 65 |
| 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 | 90.32% |
95.95%
5.6 pts worse
|
Numerator 28 · Denominator 31 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 17.39% |
25.2%
7.8 pts worse
|
Numerator 4 · Denominator 23 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 86.1% |
89.6%
3.5 pts worse
|
93.4%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 93.5% · Q2 100.0% · Q3 83.3% · Q4 71.4% · 4Q avg 86.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.3% |
91.6%
6.7 pts better
|
95.5%
2.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.3% |
3.3%
3 pts worse
|
3.3%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 7.4% · Q3 6.7% · Q4 4.8% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 97.5% |
50.3%
47.2 pts worse
|
11.4%
86.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 93.8% · Q3 98.1% · Q4 98.3% · 4Q avg 97.5% |
| Percentage of long-stay residents who lose too much weight | 7.3% |
6.5%
0.8 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.3% · Q3 9.4% · Q4 13.7% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.5% |
18.5%
About the same
|
19.6%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 19.1% · Q3 15.1% · Q4 15.4% · 4Q avg 18.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.0% |
22.8%
1.2 pts worse
|
16.7%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 20.0% · Q3 28.6% · Q4 25.6% · 4Q avg 24.0% · 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 | 5.5% |
17.2%
11.7 pts better
|
16.3%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.6% |
15.0%
11.4 pts better
|
14.9%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 5.1% · Q3 0.0% · Q4 2.2% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.1%
1.1 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.7%
1.2 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.9% |
21.3%
3.4 pts better
|
19.8%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.8% · Q2 15.3% · Q3 16.2% · Q4 20.1% · 4Q avg 17.9% |
| Percentage of long-stay residents with pressure ulcers | 6.9% |
5.2%
1.7 pts worse
|
5.1%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 3.9% · Q3 10.4% · Q4 7.8% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 24.9% |
68.8%
43.9 pts worse
|
81.7%
56.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 34.0% · Q2 33.9% · Q3 27.3% · Q4 3.8% · 4Q avg 24.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 23.0% |
14.0%
9 pts worse
|
12.0%
11 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 23.0% · Observed 33.3% · Expected 16.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 10.8% |
2.3%
8.5 pts worse
|
1.6%
9.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 16.0% · Q3 13.6% · 4Q avg 10.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 41.0% |
63.0%
22 pts worse
|
79.7%
38.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 41.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 49.5% |
26.2%
23.3 pts worse
|
23.9%
25.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 49.5% · Observed 60.0% · Expected 28.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-22 · Fire 2023-09-22
17 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-09-01 · Fire 2022-09-01
31 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (7 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-19
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-01-22
F · Potential for more than minimal harm
2024-12-19
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 2025-01-22
F · Potential for more than minimal harm
2024-12-19
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-01-22
F · Potential for more than minimal harm
2024-12-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-22
F · Potential for more than minimal harm
2024-12-19
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-01-22
F · Potential for more than minimal harm
2024-12-19
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-01-22
F · Potential for more than minimal harm
2024-12-19
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-01-22
F · Potential for more than minimal harm
2024-12-19
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-01-22
F · Potential for more than minimal harm
2024-12-19
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2025-01-22
E · Potential for more than minimal harm
2024-12-19
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-01-22
E · Potential for more than minimal harm
2024-12-19
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-01-22
E · Potential for more than minimal harm
2024-12-19
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 2025-01-22
E · Potential for more than minimal harm
2024-12-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-22
E · Potential for more than minimal harm
2024-12-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-22
E · Potential for more than minimal harm
2024-12-19
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-01-22
E · Potential for more than minimal harm
2024-12-19
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-01-22
E · Potential for more than minimal harm
2024-12-19
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2025-01-22
F · Potential for more than minimal harm
2023-09-22
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-10-23
F · Potential for more than minimal harm
2023-09-22
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-10-15
F · Potential for more than minimal harm
2023-09-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-25
F · Potential for more than minimal harm
2023-09-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-15
F · Potential for more than minimal harm
2023-09-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-10-25
F · Potential for more than minimal harm
2023-09-22
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 2023-10-25
E · Potential for more than minimal harm
2023-09-22
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-10-25
E · Potential for more than minimal harm
2023-09-22
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 2023-10-25
E · Potential for more than minimal harm
2023-09-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-15
E · Potential for more than minimal harm
2023-09-22
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-10-15
E · Potential for more than minimal harm
2023-09-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-15
F · Potential for more than minimal harm
2022-09-01
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2022-11-07
F · Potential for more than minimal harm
2022-09-01
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-11-07
F · Potential for more than minimal harm
2022-09-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-18
F · Potential for more than minimal harm
2022-09-01
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-11-28
F · Potential for more than minimal harm
2022-09-01
K930 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper storage of liquid oxygen.
Corrected 2022-11-07
E · Potential for more than minimal harm
2022-09-01
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-11-07
E · Potential for more than minimal harm
2022-09-01
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2022-11-07
E · Potential for more than minimal harm
2022-09-01
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2022-11-07
E · Potential for more than minimal harm
2022-09-01
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 2022-11-07
E · Potential for more than minimal harm
2022-09-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-11-07
E · Potential for more than minimal harm
2022-09-01
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2022-11-07
E · Potential for more than minimal harm
2022-09-01
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-11-07
E · Potential for more than minimal harm
2022-09-01
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-11-07
C · Minimal harm
2022-09-01
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-11-07
Inspection history
Recent health citations
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.
Not marked corrected
D · Potential for more than minimal harm
2026-01-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Not marked corrected
D · Potential for more than minimal harm
2025-07-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-31
E · Potential for more than minimal harm
2025-06-18
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 2025-06-25
D · Potential for more than minimal harm
2025-06-18
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-06-25
D · Potential for more than minimal harm
2025-06-18
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-06-25
D · Potential for more than minimal harm
2025-06-18
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 2025-06-25
D · Potential for more than minimal harm
2025-06-18
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 2025-06-25
D · Potential for more than minimal harm
2025-06-18
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 2025-06-25
D · Potential for more than minimal harm
2025-06-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-25
D · Potential for more than minimal harm
2025-06-18
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 2025-06-25
D · Potential for more than minimal harm
2025-06-18
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 2025-06-25
D · Potential for more than minimal harm
2025-02-26
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-01-31
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 2025-02-12
G · Actual harm
2025-01-09
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 2025-01-18
F · Potential for more than minimal harm
2024-12-19
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 2024-12-27
D · Potential for more than minimal harm
2024-12-19
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-12-27
G · Actual harm
2024-11-27
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 2024-12-09
D · Potential for more than minimal harm
2024-11-04
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 2024-11-20
L · Immediate jeopardy
2024-06-27
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-07-18
G · Actual harm
2024-06-27
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-06-27
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 2024-07-18
J · Immediate jeopardy
2024-03-18
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 2024-04-05
D · Potential for more than minimal harm
2023-12-18
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-12-27
F · Potential for more than minimal harm
2023-12-08
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 2023-12-18
F · Potential for more than minimal harm
2023-12-08
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 2023-12-18
E · Potential for more than minimal harm
2023-11-25
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 2023-12-13
G · Actual harm
2023-09-29
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 2023-10-15
D · Potential for more than minimal harm
2023-09-29
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 2023-10-15
D · Potential for more than minimal harm
2023-09-29
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-10-15
G · Actual harm
2023-09-22
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 2023-10-15
E · Potential for more than minimal harm
2023-09-22
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 2023-10-15
E · Potential for more than minimal harm
2023-09-22
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 2023-10-15
E · Potential for more than minimal harm
2023-09-22
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 2023-10-15
E · 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 2023-10-15
E · Potential for more than minimal harm
2023-09-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-15
D · Potential for more than minimal harm
2023-09-22
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-10-15
D · Potential for more than minimal harm
2023-09-22
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 2023-10-15
D · Potential for more than minimal harm
2023-09-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-15
D · Potential for more than minimal harm
2023-09-22
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-10-15
F · Potential for more than minimal harm
2023-08-27
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-09-07
D · Potential for more than minimal harm
2023-07-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-21
D · Potential for more than minimal harm
2023-07-10
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 2023-07-21
D · Potential for more than minimal harm
2023-06-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-06-19
D · Potential for more than minimal harm
2023-06-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-19
E · Potential for more than minimal harm
2023-04-19
F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-04-19
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-04-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-05-05
G · Actual harm
2022-09-01
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 2022-09-27
G · Actual harm
2022-09-01
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-09-27
F · Potential for more than minimal harm
2022-09-01
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 2022-09-27
F · Potential for more than minimal harm
2022-09-01
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 2022-10-14
F · Potential for more than minimal harm
2022-09-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-27
E · Potential for more than minimal harm
2022-09-01
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 2022-09-27
E · Potential for more than minimal harm
2022-09-01
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 2022-09-27
D · Potential for more than minimal harm
2022-09-01
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-09-27
D · Potential for more than minimal harm
2022-09-01
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2022-09-27
D · Potential for more than minimal harm
2022-09-01
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 2022-09-27
D · Potential for more than minimal harm
2022-09-01
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2022-09-27
D · Potential for more than minimal harm
2022-09-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-09-27
D · Potential for more than minimal harm
2022-09-01
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 2022-09-27
D · Potential for more than minimal harm
2022-09-01
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-09-27
Penalties and ownership
What sits behind the stars
$52,858
2024-12-19
Fine
Fine · fine $52,858
Fine
$14,050
2024-11-27
Fine
Fine · fine $14,050
Fine
$39,459
2024-06-27
Fine
Fine · fine $39,459
Fine
$78,085
2024-03-18
Fine
Fine · fine $78,085
Fine
$122,601
2023-09-22
Fine
Fine · fine $122,601
Fine
$0
2023-09-22
Payment Denial
Payment Denial · denial start 2023-10-15 · 73 days
73 day denial
Ownership
Blisko, Michael
5% Or Greater Direct Ownership Interest · Individual
Gubin Enterprises Limited Partnership
5% Or Greater Direct Ownership Interest · Organization
Wiliams, Lauren
W-2 Managing Employee · Individual
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