Villa At Evergreen Park,the
10124 South Kedzie, Evergreen Park, IL 60805


Villa At Evergreen Park,the is nursing home registered in the Centers for Medicare & Medicaid Services (CMS). The Provider Number is 145734. The address is 10124 South Kedzie, Evergreen Park, IL 60805. The zip code is 60805. The phone number is 7089077000.


Villa At Evergreen Park,the · 10124 South Kedzie, Evergreen Park, IL 60805

Federal Provider Number 145734
Provider Name VILLA AT EVERGREEN PARK,THE
Address 10124 SOUTH KEDZIE
EVERGREEN PARK, IL 60805
Phone Number 7089077000
SSA County Code 141
County Name Cook
Ownership Type For profit - Partnership
Certified Beds 242
Certified Beds Residents 144
Provider Type Medicare and Medicaid
Resides in Hospital false
Legal Business Name EVERGREEN LIVING & REHAB CENTER, LLC
Date First Approved to Provide Medicare Medicaid Services 07/15/1992
Continuing Care Retirement Community false
Special Focus Facility false
Most Recent Health Inspection More Than 2 Years Ago false
Changed Ownership Last 12 Months false
With Resident Family Council Resident
Automatic Sprinkler Systems in All Required Areas Yes
Overall Rating 2
Health Inspection Rating 1
Quality Measure Rating 5
Staffing Rating 4
RN Staffing Rating 5
Reported CNA Staffing Hours per Resident per Day 1.69132
Reported LPN Staffing Hours per Resident per Day 0.9191
Reported RN Staffing Hours per Resident per Day 1.73958
Reported Licensed Staffing Hours per Resident per Day 2.65868
Reported Total Nurse Staffing Hours per Resident per Day 4.35
Reported Physical Therapist Staffing Hours per Resident Per Day 0.24792
Expected CNA Staffing Hours per Resident per Day 2.46611
Expected LPN Staffing Hours per Resident per Day 0.71244
Expected RN Staffing Hours per Resident per Day 1.35411
Expected Total Nurse Staffing Hours per Resident per Day 4.53267
Adjusted CNA Staffing Hours per Resident per Day 1.68281
Adjusted LPN Staffing Hours per Resident per Day 1.07075
Adjusted RN Staffing Hours per Resident per Day 0.9599
Adjusted Total Nurse Staffing Hours per Resident per Day 3.86845
Cycle 1 Total Number of Health Deficiencies 12
Cycle 1 Number of Standard Health Deficiencies 4
Cycle 1 Number of Complaint Health Deficiencies 8
Cycle 1 Health Deficiency Score 88
Cycle 1 Standard Survey Health Date 05/18/2017
Cycle 1 Number of Health Revisits 1
Cycle 1 Total Health Score 88
Cycle 2 Total Number of Health Deficiencies 10
Cycle 2 Number of Standard Health Deficiencies 9
Cycle 2 Number of Complaint Health Deficiencies 1
Cycle 2 Health Deficiency Score 84
Cycle 2 Standard Health Survey Date 04/14/2016
Cycle 2 Number of Health Revisits 1
Cycle 2 Total Health Score 84
Cycle 3 Total Number of Health Deficiencies 13
Cycle 3 Number of Standard Health Deficiencies 4
Cycle 3 Number of Complaint Health Deficiencies 9
Cycle 3 Health Deficiency Score 88
Cycle 3 Standard Health Survey Date 03/18/2015
Cycle 3 Number of Health Revisits 1
Cycle 3 Total Health Score 88
Total Weighted Health Survey Score 86.667
Number of Facility Reported Incidents 1
Number of Substantiated Complaints 18
Total Amount of Fines in Dollars $0.00
Processing Date 08/01/2017

Owner or Manager · Villa At Evergreen Park,the

Owner Name Role Association Date
FNR EG LLC (Organization) 5% OR GREATER DIRECT OWNERSHIP INTEREST
NO PERCENTAGE PROVIDED
since 08/05/2013
FRIEDMAN, SUSAN (Individual) 5% OR GREATER DIRECT OWNERSHIP INTEREST
NO PERCENTAGE PROVIDED
since 08/20/2013
JACK RAJCHENBACH FAMILY TR UA 010494 (Organization) 5% OR GREATER DIRECT OWNERSHIP INTEREST
NO PERCENTAGE PROVIDED
since 08/02/2013
MULHERIN, MEGAN (Individual) MANAGING EMPLOYEE since 08/05/2013
NETZACH INVESTMENTS LLC (Organization) 5% OR GREATER DIRECT OWNERSHIP INTEREST
NO PERCENTAGE PROVIDED
since 08/02/2013
RAJCHENBACH, CHAIM (Individual) 5% OR GREATER DIRECT OWNERSHIP INTEREST
NO PERCENTAGE PROVIDED
since 08/05/2013
RAJCHENBACH, CHAIM (Individual) OPERATIONAL/MANAGERIAL CONTROL since 08/05/2013
SHABAT, MENACHEM (Individual) 5% OR GREATER DIRECT OWNERSHIP INTEREST
NO PERCENTAGE PROVIDED
since 08/01/2013
SHABAT, MENACHEM (Individual) OPERATIONAL/MANAGERIAL CONTROL since 08/01/2013
SHABAT, RONALD (Individual) 5% OR GREATER DIRECT OWNERSHIP INTEREST
NO PERCENTAGE PROVIDED
since 08/01/2013

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