Columbus Manor Res Care Home - Chicago Nursing Home
General Information
UPDATEFederal Provider Number
140000000000000000000000000000
Provider Name
COLUMBUS MANOR RES CARE HOME
Provider Address
5107 21 WEST JACKSON BOULEVARD
CHICAGO, IL 60644
CHICAGO, IL 60644
Provider Phone Number
(773) 378-5490
Provider SSA County
141
Provider County Name
Cook
Provider Website
Provider Description
Ownership Type
For profit - Corporation
Number of Certified Beds
189
Number of Residents in Certified Beds
154
Provider Type
Medicaid
Provider Resides in Hospital
N
Legal Business Name
Legal Business Name Not Available
Date First Approved to Provide Medicare and Medicaid services
1975-04-18
Continuing Care Retirement Community
N
Special Focus Facility
N
Provider Changed Ownership in Last 12 Months
N
With a Resident and Family Council
Resident
Automatic Sprinkler Systems in All Required Areas
Yes
Rating Detail Information
Overall Rating
2
Overall Rating Footnote
Health Inspection Rating
1
Health Inspection Rating Footnote
QM Rating
5
QM Rating Footnote
Staffing Rating
0
Staffing Rating Footnote
Data Not Available
RN Staffing Rating
0
RN Staffing Rating Footnote
Data Not Available
Reported Staffing Footnote
Staffing Values not Reported because of Data Quality Concerns
Physical Therapist Staffing Footnote
Physical Therapy Staffing Values not Reported because of Data Quality Concerns
Reported CNA Staffing Hours per Resident per Day
0.00000
Reported LPN Staffing Hours per Resident per Day
0.00000
Reported RN Staffing Hours per Resident per Day
0.00000
Reported Licensed Staffing Hours per Resident per Day
0.00000
Reported Total Nurse Staffing Hours per Resident per Day
0.00000
Reported Physical Therapist Staffing Hours per Resident Per Day
0.00000
Expected CNA Staffing Hours per Resident per Day
1.26556
Expected LPN Staffing Hours per Resident per Day
0.45538
Expected RN Staffing Hours per Resident per Day
0.53725
Expected Total Nurse Staffing Hours per Resident per Day
2.25819
Adjusted CNA Staffing Hours per Resident per Day
0.00000
Adjusted LPN Staffing Hours per Resident per Day
0.00000
Adjusted RN Staffing Hours per Resident per Day
0.00000
Adjusted Total Nurse Staffing Hours per Resident per Day
0.00000
Cycle 1 Total Number of Health Deficiencies
17
Cycle 1 Number of Standard Health Deficiencies
13
Cycle 1 Number of Complaint Health Deficiencies
4
Cycle 1 Health Deficiency Score
100
Cycle 1 Standard Survey Health Date
2015-03-19
Cycle 1 Number of Health Revisits
1
Cycle 1 Health Revisit Score
0
Cycle 1 Total Health Score
100
Cycle 2 Total Number of Health Deficiencies
20
Cycle 2 Number of Standard Health Deficiencies
9
Cycle 2 Number of Complaint Health Deficiencies
11
Cycle 2 Health Deficiency Score
136
Cycle 2 Standard Health Survey Date
2014-04-17
Cycle 2 Number of Health Revisits
1
Cycle 2 Health Revisit Score
0
Cycle 2 Total Health Score
136
Cycle 3 Total Number of Health Deficiencies
7
Cycle 3 Number of Standard Health Deficiencies
6
Cycle 3 Number of Complaint Health Deficiencies
1
Cycle 3 Health Deficiency Score
52
Cycle 3 Standard Health Survey Date
2013-05-31
Cycle 3 Number of Health Revisits
1
Cycle 3 Health Revisit Score
0
Cycle 3 Total Health Score
52
Total Weighted Health Survey Score
104.00000
Number of Facility Reported Incidents
15
Number of Substantiated Complaints
8
Number of Fines
0
Total Amount of Fines in Dollars
0
Number of Payment Denials
0
Total Number of Penalties
0
Location
Processing Date
2015-06-01
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