Cycle 1
Health 2024-10-24 · Fire 2024-10-24
16 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Joliet, IL
Renwick Nursing And Rehab
1-star overall rating with 1-star inspections with $213,769 in total fines with 16 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
3401 Hennepin Drive, Joliet, IL
(815) 436-5900
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
101
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Extended Care Clinical
Operator or chain grouping
Approved since
1991-05-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
12 facilities
Chain averages 2 overall / 2 health / 1 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
0.57
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
1.92
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.30
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
2.84
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.43
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
2.91
CMS adjusted total nurse staffing hours
Case-mix index
1.55
Higher values indicate more complex resident acuity
RN turnover
70%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
74%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,253
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.97
Composite VBP score used to determine payment impact.
Payment multiplier
0.9825
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.03
Baseline 25.98% · Performance 20.14% · Measure score 6.03 · Achievement 2.79 · Improvement 6.03
Healthcare-associated infections
2.36
Baseline 9.48% · Performance 8.20% · Measure score 2.36 · Achievement 0 · Improvement 2.36
Total nurse turnover
0
Performance 81.06% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.4 hours · Performance 2.92 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.62% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 146 · Observed rate 13.7% · Lower 95% interval 8.49% |
| Discharge to community | 36.81% |
50.57%
13.8 pts worse
|
Worse than the National Rate · Eligible stays 120 · Observed rate 28.33% · Lower 95% interval 28.93% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.44% |
95.27%
2.2 pts better
|
Numerator 76 · Denominator 78 |
| Falls with major injury | 1.28% |
0.77%
0.5 pts worse
|
Numerator 1 · Denominator 78 |
| Discharge self-care score | 30.61% |
53.69%
23.1 pts worse
|
Numerator 15 · Denominator 49 |
| Discharge mobility score | 28.57% |
50.94%
22.4 pts worse
|
Numerator 14 · Denominator 49 |
| Pressure ulcers or injuries, new or worsened | 2.56% |
2.29%
0.3 pts worse
|
Numerator 2 · Denominator 78 · Adjusted rate 1.7% |
| Healthcare-associated infections requiring hospitalization | 8.2% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 78 · Observed rate 11.54% · Lower 95% interval 5.15% |
| Staff COVID-19 vaccination coverage | 6.94% |
8.2%
1.3 pts worse
|
Numerator 10 · Denominator 144 |
| Staff flu vaccination coverage | 25.69% |
42%
16.3 pts worse
|
Numerator 37 · Denominator 144 |
| Discharge function score | 28.57% |
56.45%
27.9 pts worse
|
Numerator 14 · Denominator 49 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 37 · Denominator 37 |
| 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 | 21.95% |
25.2%
3.2 pts worse
|
Numerator 9 · Denominator 41 |
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 3.7 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
2.3
0.6 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 2.0 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.6% |
89.6%
1 pts worse
|
93.4%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 96.6% · Q2 94.1% · Q3 85.4% · Q4 79.1% · 4Q avg 88.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 83.5% |
91.6%
8.1 pts worse
|
95.5%
12 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 83.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.4% |
3.3%
3.1 pts worse
|
3.3%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 9.4% · Q3 6.2% · Q4 2.2% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 33.5% |
50.3%
16.8 pts better
|
11.4%
22.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 17.6% · Q3 50.6% · Q4 49.4% · 4Q avg 33.5% |
| Percentage of long-stay residents who lose too much weight | 10.5% |
6.5%
4 pts worse
|
5.4%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 13.0% · Q3 12.2% · Q4 8.0% · 4Q avg 10.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.7% |
18.5%
3.2 pts worse
|
19.6%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 22.2% · Q3 19.3% · Q4 19.2% · 4Q avg 21.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.6% |
22.8%
2.2 pts better
|
16.7%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 20.7% · Q3 20.0% · Q4 20.3% · 4Q avg 20.6% · 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 | 24.7% |
17.2%
7.5 pts worse
|
16.3%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.2% · Q2 8.2% · Q3 28.1% · Q4 36.7% · 4Q avg 24.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.7% |
15.0%
0.3 pts better
|
14.9%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 8.8% · Q3 19.0% · Q4 16.2% · 4Q avg 14.7% · 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 | 1.2% |
1.7%
0.5 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 2.1% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.7% |
21.3%
4.4 pts worse
|
19.8%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.3% · Q2 33.6% · Q3 15.8% · Q4 24.7% · 4Q avg 25.7% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
5.2%
0.6 pts better
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 4.0% · Q3 8.2% · Q4 3.4% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 29.3% |
68.8%
39.5 pts worse
|
81.7%
52.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 35.2% · Q2 24.6% · Q3 29.2% · Q4 29.0% · 4Q avg 29.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.6% |
14.0%
4.6 pts worse
|
12.0%
6.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.6% · Observed 20.3% · Expected 12.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.3% |
2.3%
3 pts worse
|
1.6%
3.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 7.4% · Q3 4.3% · Q4 6.2% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 30.6% |
63.0%
32.4 pts worse
|
79.7%
49.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 30.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.9% |
26.2%
1.7 pts worse
|
23.9%
4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.9% · Observed 29.0% · Expected 24.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-15 · Fire 2023-12-15
21 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Cycle 3
Health 2023-02-09 · Fire 2023-02-09
16 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-24
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2024-11-07
F · Potential for more than minimal harm
2024-10-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-29
F · Potential for more than minimal harm
2024-10-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-11-19
F · Potential for more than minimal harm
2024-10-24
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2024-11-20
F · Potential for more than minimal harm
2024-10-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-01
F · Potential for more than minimal harm
2024-10-24
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-01-17
F · Potential for more than minimal harm
2024-10-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-20
F · Potential for more than minimal harm
2024-10-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-18
E · Potential for more than minimal harm
2024-10-24
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-24
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 2025-01-17
E · Potential for more than minimal harm
2024-10-24
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-11-18
E · Potential for more than minimal harm
2024-10-24
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 2024-11-18
E · Potential for more than minimal harm
2024-10-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-17
F · Potential for more than minimal harm
2023-12-15
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-01-24
F · Potential for more than minimal harm
2023-12-15
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-01-24
F · Potential for more than minimal harm
2023-12-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-02
F · Potential for more than minimal harm
2023-12-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-01
F · Potential for more than minimal harm
2023-12-15
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-01-19
F · Potential for more than minimal harm
2023-12-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-01-19
F · Potential for more than minimal harm
2023-12-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-19
E · Potential for more than minimal harm
2023-12-15
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 2024-01-19
E · Potential for more than minimal harm
2023-12-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-01-19
E · Potential for more than minimal harm
2023-12-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-01-19
E · Potential for more than minimal harm
2023-12-15
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-01-19
F · Potential for more than minimal harm
2023-02-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-05
F · Potential for more than minimal harm
2023-02-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-10
F · Potential for more than minimal harm
2023-02-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-10
E · Potential for more than minimal harm
2023-02-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-03-09
E · Potential for more than minimal harm
2023-02-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-10
Inspection history
Recent health citations
F · Potential for more than minimal harm
2026-01-22
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.
Not marked corrected
F · Potential for more than minimal harm
2026-01-22
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Not marked corrected
F · Potential for more than minimal harm
2025-12-04
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-12-05
D · Potential for more than minimal harm
2025-12-04
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-05
G · Actual harm
2025-06-23
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 2025-07-02
D · Potential for more than minimal harm
2025-06-23
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-07-02
D · Potential for more than minimal harm
2025-04-26
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2025-04-28
G · Actual harm
2025-01-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-13
G · Actual harm
2024-10-24
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 2025-02-13
F · Potential for more than minimal harm
2024-10-24
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 2024-11-10
F · Potential for more than minimal harm
2024-10-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-13
E · Potential for more than minimal harm
2024-10-24
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 2024-11-10
E · Potential for more than minimal harm
2024-10-24
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 2024-11-10
E · Potential for more than minimal harm
2024-10-24
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 2024-11-10
E · Potential for more than minimal harm
2024-10-24
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-02-13
E · Potential for more than minimal harm
2024-10-24
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 2024-11-10
D · Potential for more than minimal harm
2024-10-24
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 2024-11-10
D · Potential for more than minimal harm
2024-10-24
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2024-11-10
C · Minimal harm
2024-10-24
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-11-10
E · Potential for more than minimal harm
2024-07-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-29
L · Immediate jeopardy
2024-06-17
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 2024-06-19
F · Potential for more than minimal harm
2024-06-17
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-06-25
E · Potential for more than minimal harm
2024-03-29
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 2024-04-01
D · Potential for more than minimal harm
2024-02-28
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 2024-03-13
D · Potential for more than minimal harm
2024-02-13
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2024-02-14
L · Immediate jeopardy
2024-02-01
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 2024-02-02
E · Potential for more than minimal harm
2024-02-01
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 2024-02-02
D · Potential for more than minimal harm
2024-01-13
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-02-06
G · Actual harm
2023-12-15
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-01-16
G · Actual harm
2023-12-15
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-01-16
F · Potential for more than minimal harm
2023-12-15
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 2024-01-16
F · Potential for more than minimal harm
2023-12-15
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-01-16
E · Potential for more than minimal harm
2023-12-15
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-01-16
E · Potential for more than minimal harm
2023-12-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-16
E · Potential for more than minimal harm
2023-12-15
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-01-16
D · Potential for more than minimal harm
2023-12-15
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-01-16
D · Potential for more than minimal harm
2023-12-15
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-01-16
D · Potential for more than minimal harm
2023-12-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-16
D · Potential for more than minimal harm
2023-12-15
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 2024-02-02
D · Potential for more than minimal harm
2023-12-15
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-01-16
D · Potential for more than minimal harm
2023-12-15
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-01-16
D · Potential for more than minimal harm
2023-12-15
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2024-01-16
D · Potential for more than minimal harm
2023-11-28
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 2023-12-18
E · Potential for more than minimal harm
2023-10-28
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-11-15
E · Potential for more than minimal harm
2023-10-28
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 2023-11-15
D · Potential for more than minimal harm
2023-10-24
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 2023-10-30
K · Immediate jeopardy
2023-04-03
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2023-04-18
E · Potential for more than minimal harm
2023-02-09
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 2023-03-01
E · Potential for more than minimal harm
2023-02-09
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 2023-03-01
E · Potential for more than minimal harm
2023-02-09
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2023-03-01
D · Potential for more than minimal harm
2023-02-09
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-03-01
D · Potential for more than minimal harm
2023-02-09
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 2023-03-01
D · Potential for more than minimal harm
2023-02-09
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2023-03-01
Penalties and ownership
What sits behind the stars
$22,315
2025-06-23
Fine
Fine · fine $22,315
Fine
$14,050
2024-10-24
Fine
Fine · fine $14,050
Fine
$16,065
2024-10-24
Fine
Fine · fine $16,065
Fine
$0
2024-10-24
Payment Denial
Payment Denial · denial start 2024-11-22 · 83 days
83 day denial
$14,043
2024-06-17
Fine
Fine · fine $14,043
Fine
$0
2024-06-17
Payment Denial
Payment Denial · denial start 2024-06-20 · 39 days
39 day denial
$67,977
2023-11-28
Fine
Fine · fine $67,977
Fine
$0
2023-11-28
Payment Denial
Payment Denial · denial start 2024-01-17 · 56 days
56 day denial
$79,319
2023-04-03
Fine
Fine · fine $79,319
Fine
Ownership
3401 Hennepin Member LLC
5% Or Greater Direct Ownership Interest · Organization
Nathan And Shirley Rothner Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Israel, Levi
5% Or Greater Indirect Ownership Interest · Individual
Extended Care Clinical LLC
Operational/Managerial Control · Organization
Extended Care Consulting LLC
Operational/Managerial Control · Organization
Israel, Levi
Operational/Managerial Control · Individual
Miretzky, Steven
Operational/Managerial Control · Individual
Progress, Carolyn
Operational/Managerial Control · Individual
Roth & Co, Llp
Operational/Managerial Control · Organization
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#3
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