Cycle 1
Health 2024-12-06 · Fire 2024-12-06
11 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Chicago, IL
Warren Barr Gold Coast
3-star overall rating with 3-star inspections with $24,889 in total fines with 11 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
66 West Oak Street, Chicago, IL
(312) 705-5100
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
271
Certified beds
Average residents
196
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Legacy Healthcare
Operator or chain grouping
Approved since
1978-08-01
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
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.15
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.55
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.31
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
4.01
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.70
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.88
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
1.17
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.87
CMS adjusted RN staffing hours
Adjusted total hours
3.04
CMS adjusted total nurse staffing hours
Case-mix index
1.81
Higher values indicate more complex resident acuity
RN turnover
37%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,328
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.06
Composite VBP score used to determine payment impact.
Payment multiplier
0.9858
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.07
Baseline 23.10% · Performance 20.93% · Measure score 3.07 · Achievement 1.08 · Improvement 3.07
Healthcare-associated infections
4.91
Baseline 8.97% · Performance 6.82% · Measure score 4.91 · Achievement 3.39 · Improvement 4.91
Total nurse turnover
2.96
Baseline 41.14% · Performance 51.60% · Measure score 2.96 · Achievement 2.96 · Improvement 0
Adjusted total nurse staffing
1.09
Baseline 2.65 hours · Performance 3.15 hours · Measure score 1.09 · Achievement 0 · Improvement 1.09
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.73% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 778 · Observed rate 10.67% · Lower 95% interval 8.11% |
| Discharge to community | 55.62% |
50.57%
5 pts better
|
Better than the National Rate · Eligible stays 915 · Observed rate 44.15% · Lower 95% interval 51.28% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.57% |
95.27%
4.3 pts better
|
Numerator 463 · Denominator 465 |
| Falls with major injury | 0.65% |
0.77%
0.1 pts better
|
Numerator 3 · Denominator 465 |
| Discharge self-care score | 58.66% |
53.69%
5 pts better
|
Numerator 166 · Denominator 283 |
| Discharge mobility score | 57.6% |
50.94%
6.7 pts better
|
Numerator 163 · Denominator 283 |
| Pressure ulcers or injuries, new or worsened | 1.94% |
2.29%
0.4 pts better
|
Numerator 9 · Denominator 465 · Adjusted rate 1.78% |
| Healthcare-associated infections requiring hospitalization | 6.82% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 440 · Observed rate 7.95% · Lower 95% interval 4.92% |
| Staff COVID-19 vaccination coverage | 7.47% |
8.2%
0.7 pts worse
|
Numerator 18 · Denominator 241 |
| Staff flu vaccination coverage | 46.67% |
42%
4.7 pts better
|
Numerator 112 · Denominator 240 |
| Discharge function score | 56.54% |
56.45%
0.1 pts better
|
Numerator 160 · Denominator 283 |
| Transfer of health information to provider | 99.38% |
95.95%
3.4 pts better
|
Numerator 160 · Denominator 161 |
| Transfer of health information to patient | 99.17% |
96.28%
2.9 pts better
|
Numerator 240 · Denominator 242 |
| Resident COVID-19 vaccinations up to date | 32.53% |
25.2%
7.3 pts better
|
Numerator 81 · Denominator 249 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
2.0
0.5 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 2.7 · Expected 3.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
2.3
1.1 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.6 · Expected 2.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 67.8% |
89.6%
21.8 pts worse
|
93.4%
25.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 74.3% · Q2 72.6% · Q3 61.4% · Q4 63.2% · 4Q avg 67.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 73.7% |
91.6%
17.9 pts worse
|
95.5%
21.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 73.7% |
| 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 1.5% · Q2 1.5% · Q3 1.4% · Q4 0.8% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 98.5% |
50.3%
48.2 pts worse
|
11.4%
87.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.6% · Q3 98.4% · Q4 99.1% · 4Q avg 98.5% |
| Percentage of long-stay residents who lose too much weight | 11.1% |
6.5%
4.6 pts worse
|
5.4%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 14.3% · Q3 11.9% · Q4 10.3% · 4Q avg 11.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 3.8% |
18.5%
14.7 pts better
|
19.6%
15.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 4.1% · Q3 3.7% · Q4 3.4% · 4Q avg 3.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.9% |
22.8%
18.9 pts better
|
16.7%
12.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 3.3% · Q3 1.9% · Q4 3.1% · 4Q avg 3.9% · 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 | 11.8% |
17.2%
5.4 pts better
|
16.3%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 20.6% · Q3 9.9% · Q4 5.6% · 4Q avg 11.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.2% |
15.0%
4.8 pts better
|
14.9%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 15.0% · Q3 9.8% · Q4 7.4% · 4Q avg 10.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
1.1%
0.4 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
1.7%
0.6 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.8% · Q3 1.4% · Q4 0.8% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.4% |
21.3%
1.1 pts worse
|
19.8%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.5% · Q2 24.6% · Q3 23.5% · Q4 11.6% · 4Q avg 22.4% |
| Percentage of long-stay residents with pressure ulcers | 10.3% |
5.2%
5.1 pts worse
|
5.1%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 11.6% · Q3 10.6% · Q4 8.7% · 4Q avg 10.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 40.8% |
68.8%
28 pts worse
|
81.7%
40.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 49.7% · Q2 37.1% · Q3 35.9% · Q4 39.8% · 4Q avg 40.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.9% |
14.0%
3.1 pts better
|
12.0%
1.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.9% · Observed 12.1% · Expected 12.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
2.3%
0.7 pts better
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.6% · Q3 2.1% · Q4 1.3% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 32.0% |
63.0%
31 pts worse
|
79.7%
47.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 32.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.9% |
26.2%
2.7 pts worse
|
23.9%
5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.9% · Observed 34.1% · Expected 28.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-02 · Fire 2023-11-02
12 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-12-09 · Fire 2022-12-09
23 health deficiencies
Top issue: Quality of Life and Care (12 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-06
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-12-18
E · Potential for more than minimal harm
2024-12-06
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 2024-12-18
E · Potential for more than minimal harm
2024-12-06
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-12-18
E · Potential for more than minimal harm
2024-12-06
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-12-18
E · Potential for more than minimal harm
2024-12-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-18
E · Potential for more than minimal harm
2024-12-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-18
E · Potential for more than minimal harm
2024-12-06
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-12-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-18
E · Potential for more than minimal harm
2024-12-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-12-18
F · Potential for more than minimal harm
2023-11-02
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-11-17
F · Potential for more than minimal harm
2023-11-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-11-02
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-11-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-11-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-11-02
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-11-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-11-02
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-11-17
C · Minimal harm
2023-11-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-17
F · Potential for more than minimal harm
2022-12-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-29
F · Potential for more than minimal harm
2022-12-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-12-29
E · Potential for more than minimal harm
2022-12-09
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 2022-12-31
E · Potential for more than minimal harm
2022-12-09
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2022-12-31
E · Potential for more than minimal harm
2022-12-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-12-29
E · Potential for more than minimal harm
2022-12-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-12-29
E · Potential for more than minimal harm
2022-12-09
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-12-29
E · Potential for more than minimal harm
2022-12-09
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2022-12-29
E · Potential for more than minimal harm
2022-12-09
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2022-12-29
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-09
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 2025-07-11
E · Potential for more than minimal harm
2025-07-09
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 2025-07-11
D · Potential for more than minimal harm
2025-07-09
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2025-07-11
G · Actual harm
2025-03-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-25
F · Potential for more than minimal harm
2025-02-24
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 2025-03-08
D · Potential for more than minimal harm
2025-02-24
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-03-08
F · Potential for more than minimal harm
2024-12-06
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 2024-12-17
D · Potential for more than minimal harm
2024-12-06
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-12-06
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-12-06
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-12-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-12-06
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 2024-12-17
D · Potential for more than minimal harm
2024-12-06
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-10-18
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 2024-10-19
D · Potential for more than minimal harm
2024-09-01
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 2024-09-03
D · Potential for more than minimal harm
2024-03-28
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-01-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-23
G · Actual harm
2023-12-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-01
F · Potential for more than minimal harm
2023-12-14
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 2023-12-15
D · Potential for more than minimal harm
2023-12-14
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 2024-02-01
D · Potential for more than minimal harm
2023-12-14
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-12-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-01
E · Potential for more than minimal harm
2023-12-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-12
E · Potential for more than minimal harm
2023-11-02
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 2023-11-03
E · Potential for more than minimal harm
2023-11-02
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 2023-11-03
E · Potential for more than minimal harm
2023-11-02
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-11-02
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-11-02
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 2023-11-03
D · Potential for more than minimal harm
2023-11-02
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-11-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-03
G · Actual harm
2023-10-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-10-20
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 2024-02-01
E · Potential for more than minimal harm
2023-08-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-07-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-23
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-05-05
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 2023-05-11
D · Potential for more than minimal harm
2023-05-05
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 2023-05-11
D · Potential for more than minimal harm
2023-05-05
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2023-05-11
E · Potential for more than minimal harm
2022-12-09
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 2022-12-29
E · Potential for more than minimal harm
2022-12-09
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 2022-12-29
D · Potential for more than minimal harm
2022-12-09
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-12-29
D · Potential for more than minimal harm
2022-12-09
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 2022-12-29
D · Potential for more than minimal harm
2022-12-09
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 2022-12-29
D · Potential for more than minimal harm
2022-12-09
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-12-29
D · Potential for more than minimal harm
2022-12-09
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 2022-12-29
D · Potential for more than minimal harm
2022-12-09
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2022-12-29
Penalties and ownership
What sits behind the stars
$4,784
2025-02-24
Fine
Fine · fine $4,784
Fine
$20,105
2023-10-20
Fine
Fine · fine $20,105
Fine
$0
2023-10-20
Payment Denial
Payment Denial · denial start 2023-11-16 · 77 days
77 day denial
Ownership
Rajchenbach, Chaim
5% Or Greater Direct Ownership Interest · Individual
Shabat, Menachem
5% Or Greater Direct Ownership Interest · Individual
Shabat, Ronald
5% Or Greater Direct Ownership Interest · Individual
Jack Rajchenbach Family Trust
5% Or Greater Direct Ownership Interest · Organization
Friedman, Susan
5% Or Greater Direct Ownership Interest · Individual
Fnr Wb LLC
5% Or Greater Security Interest · Organization
Rajchenbach, Chaim
Operational/Managerial Control · Individual
Shabat, Menachem
Operational/Managerial Control · Individual
Shelby, Crystal
W-2 Managing Employee · Individual
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