Nexus At Berwyn

Penalties

• Mar 13, 2026 — Fine ($26,685)
• Mar 13, 2026 — IDPH fine (Nursing Home Care Act) ($25,000)
• Dec 30, 2025 — IDPH fine (Nursing Home Care Act) ($25,000)
• Dec 12, 2025 — Fine ($135,690)
• Dec 12, 2025 — Payment Denial · payment denial 16 days
• Dec 12, 2025 — IDPH fine (Nursing Home Care Act) ($2,200)
• Dec 12, 2025 — IDPH fine (Nursing Home Care Act) ($500)
• Jul 1, 2025 — Fine ($11,349)
• Jul 1, 2025 — IDPH fine (Nursing Home Care Act) ($2,200)
• Apr 17, 2025 — IDPH fine (Nursing Home Care Act) ($25,000)
• Jan 22, 2025 — IDPH fine (Nursing Home Care Act) ($500)
• Jan 16, 2025 — Fine ($12,425)
• Jul 16, 2024 — IDPH fine (Nursing Home Care Act) ($25,000)
• Jul 16, 2024 — IDPH fine (Nursing Home Care Act) ($2,200)
• Jul 8, 2024 — IDPH fine (Nursing Home Care Act) ($2,200)
• Apr 12, 2024 — Fine ($140,530)
• Apr 12, 2024 — IDPH fine (Nursing Home Care Act) ($2,200)
• Apr 12, 2024 — Payment Denial · payment denial 74 days

Inspection findings

1. Jun 4, 2026 Health · 1 finding
   • Not serious Scope/severity F Complaint

     F0814 Nutrition and Dietary Deficiencies

     Dispose of garbage and refuse properly.

     Corrected Jun 5, 2026 · CMS health inspection

2. Mar 13, 2026 Health · 2 findings
   • Serious Scope/severity J Complaint

     F0678 Quality of Life and Care Deficiencies

     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 Mar 14, 2026 · CMS health inspection

   • Serious Scope/severity A

     Type A Illinois Nursing Home Care Act violation

     Type A: substantial probability of death or serious harm, or actual harm (1-129). Sections of the Illinois Administrative Code cited: 300.610a), 300.1035a), 300.1210b), 300.1210d)3), and 300.3240a). The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation:300.1210b) and 300.3240a).

     Statement of deficiencies (PDF)

3. Jan 30, 2026 Health · 5 findings
   • Not serious Scope/severity D Complaint

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Jan 31, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0552 Resident Rights Deficiencies

     Ensure that residents are fully informed and understand their health status, care and treatments.

     Corrected Jan 31, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Jan 31, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected Jan 31, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Jan 31, 2026 · CMS health inspection

4. Dec 30, 2025 Health · 2 findings
   • Serious Scope/severity J Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Dec 31, 2025 · CMS health inspection

   • Serious Scope/severity A

     Type A Illinois Nursing Home Care Act violation

     Type A: substantial probability of death or serious harm, or actual harm (1-129). Sections of the Illinois Administrative Code cited: 300.610a), 300.1210b), and 300.1210d)6). The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation:300.1210b) and 300.1210d)6).

     Statement of deficiencies (PDF)

5. Dec 22, 2025 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0921 Environmental Deficiencies

     Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

     Corrected Dec 23, 2025 · CMS health inspection

6. Dec 12, 2025 Health · 4 findings
   • Not serious Scope/severity D Complaint

     F0585 Resident Rights Deficiencies

     Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

     Corrected Dec 13, 2025 · CMS health inspection

   • Serious Scope/severity G Complaint

     F0690 Quality of Life and Care Deficiencies

     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 Dec 13, 2025 · CMS health inspection

   • Not serious Scope/severity B

     Type B Illinois Nursing Home Care Act violation

     Type B: more likely than not to cause more than minimal harm (1-130). Sections of the Illinois Administrative Code cited: 300.610a), 300.696b), 300.696d)1), 300.1210b)3), and 300.1210d)2). The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation:300.696 and 300.1210b).

     Statement of deficiencies (PDF)

   • Not serious Scope/severity C

     Type C Illinois Nursing Home Care Act violation

     Type C: less than minimal harm (1-132). Sections of the Illinois Administrative Code cited: 300.615e). The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation:300.615e).

     Statement of deficiencies (PDF)

7. Sep 30, 2025 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Oct 3, 2025 · CMS health inspection

8. Sep 11, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Sep 12, 2025 · CMS health inspection

9. Jul 1, 2025 Health · 3 findings
   • Not serious Scope/severity D Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Jul 2, 2025 · CMS health inspection

   • Serious Scope/severity G Complaint

     F0697 Quality of Life and Care Deficiencies

     Provide safe, appropriate pain management for a resident who requires such services.

     Corrected Jul 2, 2025 · CMS health inspection

   • Not serious Scope/severity B

     Type B Illinois Nursing Home Care Act violation

     Type B: more likely than not to cause more than minimal harm (1-130). Sections of the Illinois Administrative Code cited: 300.610a), 300.1210b), and 300.1210d)1)2) The fine was doubled in this instance in accordance with 330.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation: 300.1210b).

     Statement of deficiencies (PDF)

10. Jun 9, 2025 Health · 2 findings
    • Not serious Scope/severity D Complaint

      F0761 Pharmacy Service Deficiencies

      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 Jun 10, 2025 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0921 Environmental Deficiencies

      Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

      Corrected Jun 10, 2025 · CMS health inspection

11. Apr 17, 2025 Health · 2 findings
    • Serious Scope/severity G Complaint

      F0689 Quality of Life and Care Deficiencies

      Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

      Corrected Apr 18, 2025 · CMS health inspection

    • Serious Scope/severity A

      Type A Illinois Nursing Home Care Act violation

      Type A: substantial probability of death or serious harm, or actual harm (1-129). Sections of the Illinois Administrative Code cited: 300.1210b), 300.1210c), and 300.1210d)6). The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation: 300.1210b) and 300.1210d)6).

      Statement of deficiencies (PDF)

12. Mar 22, 2025 Health · 1 finding
    • Not serious Scope/severity D Complaint

      F0695 Quality of Life and Care Deficiencies

      Provide safe and appropriate respiratory care for a resident when needed.

      Corrected Mar 24, 2025 · CMS health inspection

13. Feb 28, 2025 Fire Safety · 23 findings
    • Not serious Scope/severity F

      E0024 Emergency Preparedness Deficiencies

      Establish policies and procedures for volunteers.

      Corrected Mar 5, 2025 · CMS fire safety

    • Not serious Scope/severity D

      F0558 Resident Rights Deficiencies

      Reasonably accommodate the needs and preferences of each resident.

      Corrected Mar 3, 2025 · CMS health inspection

    • Not serious Scope/severity D

      F0677 Quality of Life and Care Deficiencies

      Provide care and assistance to perform activities of daily living for any resident who is unable.

      Corrected Mar 3, 2025 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0686 Quality of Life and Care Deficiencies

      Provide appropriate pressure ulcer care and prevent new ulcers from developing.

      Corrected Mar 3, 2025 · CMS health inspection

    • Not serious Scope/severity D

      F0688 Quality of Life and Care Deficiencies

      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 Mar 3, 2025 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0689 Quality of Life and Care Deficiencies

      Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

      Corrected Mar 3, 2025 · CMS health inspection

    • Not serious Scope/severity D

      F0759 Pharmacy Service Deficiencies

      Ensure medication error rates are not 5 percent or greater.

      Corrected Mar 3, 2025 · CMS health inspection

    • Not serious Scope/severity E

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Mar 3, 2025 · CMS health inspection

    • Not serious Scope/severity E

      K0211 Egress Deficiencies

      Keep aisles, corridors, and exits free of obstruction in case of emergency.

      Corrected Mar 5, 2025 · CMS fire safety

    • Not serious Scope/severity E

      K0232 Egress Deficiencies

      Have corridors or aisles that are unobstructed and are at least 8 feet in width.

      Corrected Mar 5, 2025 · CMS fire safety

    • Not serious Scope/severity E

      K0311 Smoke Deficiencies

      Have an enclosure around a vertical opening shaft.

      Corrected Mar 5, 2025 · CMS fire safety

    • Not serious Scope/severity E

      K0321 Smoke Deficiencies

      Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

      Corrected Mar 5, 2025 · CMS fire safety

    • Not serious Scope/severity E

      K0324 Smoke Deficiencies

      Provide properly protected cooking facilities.

      Corrected Mar 21, 2025 · CMS fire safety

    • Not serious Scope/severity E

      K0325 Smoke Deficiencies

      Have properly installed hallway dispensers for alcohol-based hand rub.

      Corrected Mar 5, 2025 · CMS fire safety

    • Not serious Scope/severity F

      K0345 Smoke Deficiencies

      Have approved installation, maintenance and testing program for fire alarm systems.

      Corrected Mar 19, 2025 · CMS fire safety

    • Not serious Scope/severity F

      K0353 Smoke Deficiencies

      Inspect, test, and maintain automatic sprinkler systems.

      Corrected Mar 5, 2025 · CMS fire safety

    • Not serious Scope/severity E

      K0362 Smoke Deficiencies

      Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

      Corrected Mar 5, 2025 · CMS fire safety

    • Not serious Scope/severity E

      K0363 Smoke Deficiencies

      Install corridor and hallway doors that block smoke.

      Corrected Mar 5, 2025 · CMS fire safety

    • Not serious Scope/severity E

      K0754 Miscellaneous Deficiencies

      Provide properly sized and located linen or trash receptacles.

      Corrected Mar 5, 2025 · CMS fire safety

    • Not serious Scope/severity E

      K0761 Miscellaneous Deficiencies

      To conduct inspection, testing and maintenance of fire doors by qualified individuals.

      Corrected Mar 5, 2025 · CMS fire safety

    • Not serious Scope/severity E

      K0781 Miscellaneous Deficiencies

      Have restrictions on the use of portable space heaters.

      Corrected Mar 5, 2025 · CMS fire safety

    • Not serious Scope/severity F

      K0918 Gas, Vacuum, and Electrical Systems Deficiencies

      Have generator or other power source capable of supplying service within 10 seconds.

      Corrected Mar 19, 2025 · CMS fire safety

    • Not serious Scope/severity E

      K0920 Gas, Vacuum, and Electrical Systems Deficiencies

      Ensure proper usage of power strips and extension cords.

      Corrected Mar 5, 2025 · CMS fire safety

14. Jan 22, 2025 Health · 2 findings
    • Serious Scope/severity G Complaint

      F0689 Quality of Life and Care Deficiencies

      Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

      Corrected Jan 23, 2025 · CMS health inspection

    • Not serious Scope/severity C

      Type C Illinois Nursing Home Care Act violation

      Type C: less than minimal harm (1-132). Sections of the Illinois Administrative Code cited: 300.610a), 300.690b), 300.690c), 300.1210b), and 300.1210d)6). The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation: 300.690, 300.1210b), and 300.1210d)6).

      Statement of deficiencies (PDF)

15. Jan 16, 2025 Health · 1 finding
    • Not serious Scope/severity D Complaint

      F0684 Quality of Life and Care Deficiencies

      Provide appropriate treatment and care according to orders, resident’s preferences and goals.

      Corrected Jan 17, 2025 · CMS health inspection

16. Dec 23, 2024 Health · 1 finding
    • Not serious Scope/severity D Complaint

      F0576 Resident Rights Deficiencies

      Ensure residents have reasonable access to and privacy in their use of communication methods.

      Corrected Dec 24, 2024 · CMS health inspection

17. Sep 13, 2024 Health · 2 findings
    • Not serious Scope/severity D Complaint

      F0684 Quality of Life and Care Deficiencies

      Provide appropriate treatment and care according to orders, resident’s preferences and goals.

      Corrected Sep 20, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0755 Pharmacy Service Deficiencies

      Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

      Corrected Sep 20, 2024 · CMS health inspection

18. Jul 16, 2024 Health · 3 findings
    • Serious Scope/severity G Complaint

      F0684 Quality of Life and Care Deficiencies

      Provide appropriate treatment and care according to orders, resident’s preferences and goals.

      Corrected Jul 22, 2024 · CMS health inspection

    • Serious Scope/severity A

      Type A Illinois Nursing Home Care Act violation

      Type A: substantial probability of death or serious harm, or actual harm (1-129). Sections of the Illinois Administrative Code cited: 300.610a), 300.690b), 300.690c), 300.1210b), 300.1210c), 300.3210t), 300.3240b), 300.3240c), and 300.3240e). The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation: 300.690), 300.1210b) and 300.3240e).

      Statement of deficiencies (PDF)

    • Not serious Scope/severity B

      Type B Illinois Nursing Home Care Act violation

      Type B: more likely than not to cause more than minimal harm (1-130). Sections of the Illinois Administrative Code cited: 300.610a), 300.1210b), 300.1210d)3)4)A)B), and 300.3240a), The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation: 300.1210b) and 300.3240a).

      Statement of deficiencies (PDF)

19. Jul 8, 2024 Health · 4 findings
    • Not serious Scope/severity D Complaint

      F0660 Resident Assessment and Care Planning Deficiencies

      Plan the resident's discharge to meet the resident's goals and needs.

      Corrected Jul 22, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0684 Quality of Life and Care Deficiencies

      Provide appropriate treatment and care according to orders, resident’s preferences and goals.

      Corrected Jul 22, 2024 · CMS health inspection

    • Serious Scope/severity G Complaint

      F0758 Pharmacy Service Deficiencies

      Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

      Corrected Jul 22, 2024 · CMS health inspection

    • Not serious Scope/severity B

      Type B Illinois Nursing Home Care Act violation

      Type B: more likely than not to cause more than minimal harm (1-130). Sections of the Illinois Administrative Code cited: 300.610a) and 300.1210b). The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation: 300.1210b).

      Statement of deficiencies (PDF)

20. Apr 25, 2024 Health · 25 findings
    • Not serious Scope/severity D

      F0645 Resident Assessment and Care Planning Deficiencies

      PASARR screening for Mental disorders or Intellectual Disabilities

      Corrected May 7, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0656 Resident Assessment and Care Planning Deficiencies

      Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

      Corrected May 7, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0658 Resident Assessment and Care Planning Deficiencies

      Ensure services provided by the nursing facility meet professional standards of quality.

      Corrected May 7, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0677 Quality of Life and Care Deficiencies

      Provide care and assistance to perform activities of daily living for any resident who is unable.

      Corrected May 7, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0725 Nursing and Physician Services Deficiencies

      Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

      Corrected May 7, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0740 Quality of Life and Care Deficiencies

      Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

      Corrected May 7, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0759 Pharmacy Service Deficiencies

      Ensure medication error rates are not 5 percent or greater.

      Corrected May 7, 2024 · CMS health inspection

    • Not serious Scope/severity F

      F0761 Pharmacy Service Deficiencies

      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 May 7, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected May 7, 2024 · CMS health inspection

    • Not serious Scope/severity E

      K0222 Egress Deficiencies

      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 May 2, 2024 · CMS fire safety

    • Not serious Scope/severity F

      K0293 Egress Deficiencies

      Have properly located and lighted "Exit" signs.

      Corrected May 2, 2024 · CMS fire safety

    • Not serious Scope/severity E

      K0311 Smoke Deficiencies

      Have an enclosure around a vertical opening shaft.

      Corrected May 2, 2024 · CMS fire safety

    • Not serious Scope/severity E

      K0321 Smoke Deficiencies

      Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

      Corrected May 2, 2024 · CMS fire safety

    • Not serious Scope/severity E

      K0324 Smoke Deficiencies

      Provide properly protected cooking facilities.

      Corrected Jun 5, 2024 · CMS fire safety

    • Not serious Scope/severity E

      K0351 Smoke Deficiencies

      Install an approved automatic sprinkler system.

      Corrected Jul 8, 2024 · CMS fire safety

    • Not serious Scope/severity F

      K0353 Smoke Deficiencies

      Inspect, test, and maintain automatic sprinkler systems.

      Corrected May 2, 2024 · CMS fire safety

    • Not serious Scope/severity F

      K0355 Smoke Deficiencies

      Properly select, install, inspect, or maintain portable fire extinguishes.

      Corrected Jun 5, 2024 · CMS fire safety

    • Not serious Scope/severity E

      K0362 Smoke Deficiencies

      Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

      Corrected Jul 1, 2024 · CMS fire safety

    • Not serious Scope/severity E

      K0363 Smoke Deficiencies

      Install corridor and hallway doors that block smoke.

      Corrected May 2, 2024 · CMS fire safety

    • Not serious Scope/severity F

      K0531 Services Deficiencies

      Have elevators that firefighters can control in the event of a fire.

      Corrected May 2, 2024 · CMS fire safety

    • Not serious Scope/severity F

      K0712 Miscellaneous Deficiencies

      Have simulated fire drills held at unexpected times.

      Corrected May 2, 2024 · CMS fire safety

    • Not serious Scope/severity E

      K0781 Miscellaneous Deficiencies

      Have restrictions on the use of portable space heaters.

      Corrected May 2, 2024 · CMS fire safety

    • Not serious Scope/severity E

      K0911 Gas, Vacuum, and Electrical Systems Deficiencies

      Meet requirements for the installation and maintenance of electrical systems.

      Corrected May 2, 2024 · CMS fire safety

    • Not serious Scope/severity F

      K0915 Gas, Vacuum, and Electrical Systems Deficiencies

      Have proper power supply for life support equipment.

      Corrected Mar 4, 2025 · CMS fire safety

    • Not serious Scope/severity D

      K0920 Gas, Vacuum, and Electrical Systems Deficiencies

      Ensure proper usage of power strips and extension cords.

      Corrected May 2, 2024 · CMS fire safety

21. Apr 12, 2024 Health · 4 findings
    • Not serious Scope/severity D Complaint

      F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

      Corrected Apr 19, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

      Corrected Apr 19, 2024 · CMS health inspection

    • Serious Scope/severity G Complaint

      F0689 Quality of Life and Care Deficiencies

      Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

      Corrected Apr 19, 2024 · CMS health inspection

    • Not serious Scope/severity B

      Type B Illinois Nursing Home Care Act violation

      Type B: more likely than not to cause more than minimal harm (1-130). Sections of the Illinois Administrative Code cited: 300.610a), 300.1210b), and 300.1210d)6). The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation: 300.1210b) and 300.1210d)6).

      Statement of deficiencies (PDF)

22. Dec 2, 2022 Fire Safety · 22 findings
    • Not serious Scope/severity F

      E0004 Emergency Preparedness Deficiencies

      Develop and maintain an Emergency Preparedness Program (EP).

      Corrected Dec 22, 2022 · CMS fire safety

    • Not serious Scope/severity F

      E0030 Emergency Preparedness Deficiencies

      List the names and contact information of those in the facility.

      Corrected Dec 22, 2022 · CMS fire safety

    • Not serious Scope/severity D

      F0583 Resident Rights Deficiencies

      Keep residents' personal and medical records private and confidential.

      Corrected Dec 14, 2022 · CMS health inspection

    • Not serious Scope/severity D

      F0657 Resident Assessment and Care Planning Deficiencies

      Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

      Corrected Dec 14, 2022 · CMS health inspection

    • Not serious Scope/severity D

      F0684 Quality of Life and Care Deficiencies

      Provide appropriate treatment and care according to orders, resident’s preferences and goals.

      Corrected Dec 14, 2022 · CMS health inspection

    • Not serious Scope/severity D

      F0693 Quality of Life and Care Deficiencies

      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 Dec 14, 2022 · CMS health inspection

    • Not serious Scope/severity D

      F0695 Quality of Life and Care Deficiencies

      Provide safe and appropriate respiratory care for a resident when needed.

      Corrected Dec 14, 2022 · CMS health inspection

    • Not serious Scope/severity D

      F0761 Pharmacy Service Deficiencies

      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 Dec 14, 2022 · CMS health inspection

    • Not serious Scope/severity E

      K0222 Egress Deficiencies

      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 Dec 22, 2022 · CMS fire safety

    • Not serious Scope/severity E

      K0225 Egress Deficiencies

      Have stairways and smokeproof enclosures used as exits that meet safety requirements.

      Corrected Dec 22, 2022 · CMS fire safety

    • Not serious Scope/severity F

      K0291 Egress Deficiencies

      Install emergency lighting that can last at least 1 1/2 hours.

      Corrected Dec 22, 2022 · CMS fire safety

    • Not serious Scope/severity E

      K0293 Egress Deficiencies

      Have properly located and lighted "Exit" signs.

      Corrected Dec 22, 2022 · CMS fire safety

    • Not serious Scope/severity E

      K0311 Smoke Deficiencies

      Have an enclosure around a vertical opening shaft.

      Corrected Dec 22, 2022 · CMS fire safety

    • Not serious Scope/severity E

      K0321 Smoke Deficiencies

      Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

      Corrected Dec 22, 2022 · CMS fire safety

    • Not serious Scope/severity E

      K0351 Smoke Deficiencies

      Install an approved automatic sprinkler system.

      Corrected Dec 22, 2022 · CMS fire safety

    • Not serious Scope/severity F

      K0353 Smoke Deficiencies

      Inspect, test, and maintain automatic sprinkler systems.

      Corrected Dec 22, 2022 · CMS fire safety

    • Not serious Scope/severity E

      K0362 Smoke Deficiencies

      Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

      Corrected Dec 22, 2022 · CMS fire safety

    • Not serious Scope/severity E

      K0374 Smoke Deficiencies

      Install smoke barrier doors that can resist smoke for at least 20 minutes.

      Corrected Dec 22, 2022 · CMS fire safety

    • Not serious Scope/severity F

      K0511 Services Deficiencies

      Have properly installed electrical wiring and gas equipment.

      Corrected Dec 22, 2022 · CMS fire safety

    • Not serious Scope/severity F

      K0531 Services Deficiencies

      Have elevators that firefighters can control in the event of a fire.

      Corrected Dec 22, 2022 · CMS fire safety

    • Not serious Scope/severity E

      K0541 Services Deficiencies

      Install properly constructed and protected linen or trash chutes.

      Corrected Dec 22, 2022 · CMS fire safety

    • Not serious Scope/severity E

      K0920 Gas, Vacuum, and Electrical Systems Deficiencies

      Ensure proper usage of power strips and extension cords.

      Corrected Dec 22, 2022 · CMS fire safety

Owners and managers (as published by CMS)

• RAJCHENBACH, CHAIM — corporate officer, NOT APPLICABLE, since 02/01/2019
• SEIFER, GIANNI — w-2 managing employee, NOT APPLICABLE, since 03/21/2022
• SHABAT, MENACHEM — corporate officer, NOT APPLICABLE, since 02/01/2019
• DOROS GENERATION TRUST U/A/D 1/3/12 — 5% or greater direct ownership interest, 50%, since 02/01/2018
• GPN FAMILY TRUST U/A/D 4/28/08 — 5% or greater direct ownership interest, 50%, since 02/01/2019
• LEGACY HEALTHCARE FINANCIAL SERVICES LLC — operational/managerial control, NOT APPLICABLE, since 02/01/2019