Waverly Place of Stockton
501 East Front Street, Po Box #38, Stockton, IL 61085


Waverly Place of Stockton is nursing home registered in the Centers for Medicare & Medicaid Services (CMS). The Provider Number is 146147. The address is 501 East Front Street, Po Box #38, Stockton, IL 61085. The zip code is 61085. The phone number is 8159472215.


Waverly Place of Stockton · 501 East Front Street, Po Box #38, Stockton, IL 61085

Federal Provider Number 146147
Provider Name WAVERLY PLACE OF STOCKTON
Address 501 EAST FRONT STREET, PO BOX #38
STOCKTON, IL 61085
Phone Number 8159472215
SSA County Code 510
County Name Jo Daviess
Ownership Type For profit - Partnership
Certified Beds 49
Certified Beds Residents 42
Provider Type Medicare and Medicaid
Resides in Hospital false
Legal Business Name WAVERLY PLACE OF STOCKTON, LLC
Date First Approved to Provide Medicare Medicaid Services 05/30/2011
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 1
Health Inspection Rating 1
Quality Measure Rating 2
Staffing Rating 2
RN Staffing Rating 3
Reported CNA Staffing Hours per Resident per Day 1.66786
Reported LPN Staffing Hours per Resident per Day 0.24643
Reported RN Staffing Hours per Resident per Day 0.64048
Reported Licensed Staffing Hours per Resident per Day 0.8869
Reported Total Nurse Staffing Hours per Resident per Day 2.55477
Reported Physical Therapist Staffing Hours per Resident Per Day 0.03095
Expected CNA Staffing Hours per Resident per Day 2.55747
Expected LPN Staffing Hours per Resident per Day 0.68826
Expected RN Staffing Hours per Resident per Day 1.11387
Expected Total Nurse Staffing Hours per Resident per Day 4.3596
Adjusted CNA Staffing Hours per Resident per Day 1.60019
Adjusted LPN Staffing Hours per Resident per Day 0.29718
Adjusted RN Staffing Hours per Resident per Day 0.42964
Adjusted Total Nurse Staffing Hours per Resident per Day 2.36215
Cycle 1 Total Number of Health Deficiencies 6
Cycle 1 Number of Standard Health Deficiencies 6
Cycle 1 Health Deficiency Score 36
Cycle 1 Standard Survey Health Date 05/17/2017
Cycle 1 Number of Health Revisits 1
Cycle 1 Total Health Score 36
Cycle 2 Total Number of Health Deficiencies 13
Cycle 2 Number of Standard Health Deficiencies 8
Cycle 2 Number of Complaint Health Deficiencies 5
Cycle 2 Health Deficiency Score 88
Cycle 2 Standard Health Survey Date 07/20/2016
Cycle 2 Number of Health Revisits 1
Cycle 2 Total Health Score 88
Cycle 3 Total Number of Health Deficiencies 24
Cycle 3 Number of Standard Health Deficiencies 13
Cycle 3 Number of Complaint Health Deficiencies 13
Cycle 3 Health Deficiency Score 357
Cycle 3 Standard Health Survey Date 06/19/2015
Cycle 3 Number of Health Revisits 2
Cycle 3 Health Revisit Score 179
Cycle 3 Total Health Score 536
Total Weighted Health Survey Score 136.667
Number of Facility Reported Incidents 1
Number of Substantiated Complaints 17
Number of Fines 3
Total Amount of Fines in Dollars $91390.00
Number of Payment Denials 1
Total Number of Penalties 4
Processing Date 08/01/2017

Owner or Manager · Waverly Place of Stockton

Owner Name Role Association Date
COOK, KARI (Individual) MANAGING EMPLOYEE since 04/16/2015
GOLDBERG, JEREMY (Individual) 5% OR GREATER DIRECT OWNERSHIP INTEREST
50%
since 03/09/2015
GOLDBERG, JEREMY (Individual) OPERATIONAL/MANAGERIAL CONTROL since 03/09/2015
MILLER, GINA (Individual) MANAGING EMPLOYEE since 04/16/2015
NUDELL, MICHAEL (Individual) 5% OR GREATER DIRECT OWNERSHIP INTEREST
50%
since 03/09/2015
NUDELL, MICHAEL (Individual) OPERATIONAL/MANAGERIAL CONTROL since 03/09/2015

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