Cycle 1
Health 2025-04-23 · Fire 2025-04-23
11 health deficiencies
Top issue: Infection Control (3 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Deerfield, IL
Whitehall Of Deerfield
3-star overall rating with 3-star inspections with 11 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
300 Waukegan Road, Deerfield, IL
(847) 945-4600
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
190
Certified beds
Average residents
132
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Legacy Healthcare
Operator or chain grouping
Approved since
1991-12-01
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
1.45
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.37
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
4.60
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
2.24
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
4.45
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
1.47
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.28
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.22
CMS adjusted RN staffing hours
Adjusted total hours
3.86
CMS adjusted total nurse staffing hours
Case-mix index
1.63
Higher values indicate more complex resident acuity
RN turnover
48%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,761
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.81
Composite VBP score used to determine payment impact.
Payment multiplier
0.9958
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.87
Baseline 20.73% · Performance 21.03% · Measure score 0.87 · Achievement 0.87 · Improvement 0
Healthcare-associated infections
8.76
Baseline 5.17% · Performance 5.22% · Measure score 8.76 · Achievement 8.76 · Improvement 0
Total nurse turnover
3.9
Baseline 34.87% · Performance 47.74% · Measure score 3.9 · Achievement 3.9 · Improvement 0
Adjusted total nurse staffing
3.59
Baseline 4.61 hours · Performance 4.1 hours · Measure score 3.59 · Achievement 3.59 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.68% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 1587 · Observed rate 7.56% · Lower 95% interval 8.01% |
| Discharge to community | 66.99% |
50.57%
16.4 pts better
|
Better than the National Rate · Eligible stays 1668 · Observed rate 66.85% · Lower 95% interval 64.96% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.08% |
95.27%
3.8 pts better
|
Numerator 969 · Denominator 978 |
| Falls with major injury | 0.31% |
0.77%
0.5 pts better
|
Numerator 3 · Denominator 978 |
| Discharge self-care score | 51.66% |
53.69%
2 pts worse
|
Numerator 358 · Denominator 693 |
| Discharge mobility score | 64.79% |
50.94%
13.9 pts better
|
Numerator 449 · Denominator 693 |
| Pressure ulcers or injuries, new or worsened | 1.43% |
2.29%
0.9 pts better
|
Numerator 14 · Denominator 978 · Adjusted rate 1.73% |
| Healthcare-associated infections requiring hospitalization | 5.22% |
7.12%
1.9 pts better
|
Better than the National Rate · Eligible stays 932 · Observed rate 3.97% · Lower 95% interval 3.91% |
| Staff COVID-19 vaccination coverage | 5.73% |
8.2%
2.5 pts worse
|
Numerator 15 · Denominator 262 |
| Staff flu vaccination coverage | 33.68% |
42%
8.3 pts worse
|
Numerator 97 · Denominator 288 |
| Discharge function score | 63.92% |
56.45%
7.5 pts better
|
Numerator 443 · Denominator 693 |
| Transfer of health information to provider | 99.26% |
95.95%
3.3 pts better
|
Numerator 801 · Denominator 807 |
| Transfer of health information to patient | 98.86% |
96.28%
2.6 pts better
|
Numerator 87 · Denominator 88 |
| Resident COVID-19 vaccinations up to date | 40.62% |
25.2%
15.4 pts better
|
Numerator 197 · Denominator 485 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.0
0.2 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.3 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
2.3
1.3 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
89.6%
9 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 100.0% · Q3 98.1% · Q4 98.0% · 4Q avg 98.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.7% |
91.6%
0.1 pts better
|
95.5%
3.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.5% |
3.3%
2.8 pts better
|
3.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 33.2% |
50.3%
17.1 pts better
|
11.4%
21.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.4% · Q2 29.6% · Q3 40.4% · Q4 38.1% · 4Q avg 33.2% |
| Percentage of long-stay residents who lose too much weight | 6.6% |
6.5%
0.1 pts worse
|
5.4%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 2.2% · Q3 4.3% · Q4 7.5% · 4Q avg 6.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.1% |
18.5%
8.4 pts better
|
19.6%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 10.4% · Q3 14.9% · Q4 7.5% · 4Q avg 10.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.4% |
22.8%
8.4 pts better
|
16.7%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 15.0% · Q3 11.6% · Q4 11.1% · 4Q avg 14.4% · 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 | 12.1% |
17.2%
5.1 pts better
|
16.3%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 11.0% · Q3 5.9% · Q4 25.0% · 4Q avg 12.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.8% |
15.0%
0.8 pts worse
|
14.9%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 18.2% · Q3 18.6% · Q4 17.1% · 4Q avg 15.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.3% |
1.1%
1.2 pts worse
|
1.0%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.7% · Q3 2.9% · Q4 4.1% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
1.7%
0.7 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.0% · Q4 2.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.8% |
21.3%
10.5 pts worse
|
19.8%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 34.0% · Q3 32.4% · Q4 35.4% · 4Q avg 31.8% |
| Percentage of long-stay residents with pressure ulcers | 13.8% |
5.2%
8.6 pts worse
|
5.1%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 15.7% · Q3 6.7% · Q4 16.3% · 4Q avg 13.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.1% |
68.8%
19.3 pts better
|
81.7%
6.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.7% · Q2 87.7% · Q3 87.4% · Q4 88.7% · 4Q avg 88.1% |
| 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 9.3% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
2.3%
0.8 pts better
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 2.0% · Q3 1.9% · Q4 1.1% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 68.7% |
63.0%
5.7 pts better
|
79.7%
11 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 68.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.6% |
26.2%
0.4 pts worse
|
23.9%
2.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.6% · Observed 23.4% · Expected 21.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-30 · Fire 2024-05-30
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Cycle 3
Health 2023-06-07 · Fire 2023-06-07
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-23
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-05-21
F · Potential for more than minimal harm
2025-04-23
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2025-05-21
F · Potential for more than minimal harm
2025-04-23
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2025-05-21
F · Potential for more than minimal harm
2024-05-30
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-07-23
F · Potential for more than minimal harm
2024-05-30
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2024-07-23
F · Potential for more than minimal harm
2024-05-30
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2024-07-23
F · Potential for more than minimal harm
2024-05-30
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-07-23
F · Potential for more than minimal harm
2024-05-30
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-07-23
F · Potential for more than minimal harm
2024-05-30
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-07-23
F · Potential for more than minimal harm
2024-05-30
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-07-23
E · Potential for more than minimal harm
2023-06-07
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-06-28
Inspection history
Recent health citations
F · Potential for more than minimal harm
2026-01-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-23
F · Potential for more than minimal harm
2025-04-23
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 2025-04-26
F · Potential for more than minimal harm
2025-04-23
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 2025-04-26
E · Potential for more than minimal harm
2025-04-23
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 2025-04-26
E · Potential for more than minimal harm
2025-04-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-26
D · Potential for more than minimal harm
2025-04-23
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 2025-04-26
D · Potential for more than minimal harm
2025-04-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-26
D · Potential for more than minimal harm
2025-04-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-26
D · Potential for more than minimal harm
2025-04-23
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 2025-04-26
D · Potential for more than minimal harm
2025-04-23
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 2025-04-26
D · Potential for more than minimal harm
2025-04-23
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-04-26
D · Potential for more than minimal harm
2024-12-18
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 2024-12-20
D · Potential for more than minimal harm
2024-12-18
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 2024-12-20
D · Potential for more than minimal harm
2024-12-03
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 2024-12-04
F · Potential for more than minimal harm
2024-05-30
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 2024-06-13
D · Potential for more than minimal harm
2024-05-30
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 2024-06-13
D · Potential for more than minimal harm
2024-05-30
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-06-13
D · Potential for more than minimal harm
2024-05-30
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 2024-06-13
D · Potential for more than minimal harm
2024-05-30
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-06-13
D · Potential for more than minimal harm
2024-04-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-03
D · Potential for more than minimal harm
2023-10-30
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-11-06
E · Potential for more than minimal harm
2023-06-07
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-06-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-06-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-06-07
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-06-07
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-06-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-12
Penalties and ownership
What sits behind the stars
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
Rajchenbach 2015 Family Trust
5% Or Greater Direct Ownership Interest · Organization
Oakway Operations LLC
5% Or Greater Direct Ownership Interest · Organization
Cohen, Cindy
Operational/Managerial Control · Individual
Forbright Bank
Operational/Managerial Control · Organization
Forbright Bank
5% Or Greater Security Interest · Organization
Legacy Healthcare Financial Services LLC
Operational/Managerial Control · Organization
Shabat, Menachem
Operational/Managerial Control · Individual
Sultan, John
Operational/Managerial Control · Individual
Wh North Property, LLC
5% Or Greater Security Interest · Organization
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#3
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