Clark City Sd Skilled Nursing Facility LLC

Mixed CMS roles

Provider / enrollment organization Enrollment PAC 5092043232 Enrollment ID O20190826001446

Linked facilitiesFacilities

15 parties: 7 organizations · 8 individuals

Owners & control parties

Name	Owner/control PAC	Type	Role(s)	%
Bokf, Na	0648188896	Organization	5% or Greater Security Interest; Operational/Managerial Control	100
Edward A Dickes	8325289663	Individual	Operational/Managerial Control; ADP of the SNF	—
Rachel Morehouse	7517433576	Individual	Operational/Managerial Control; ADP of the SNF	—
Chaim Rajchenbach	4284547977	Individual	Operational/Managerial Control; Managing Control - Governing Body; ADP of the SNF	—
Menachem Shabat	3072526219	Individual	Operational/Managerial Control; Managing Control - Governing Body; ADP of the SNF	—
Doros Generation Trust U/A/D 1/3/12	6901110428	Organization	5% or Greater Direct Ownership Interest; ADP of the SNF	42.5
Gpn Family Trust U/A/D 4/28/08	5294988994	Organization	5% or Greater Direct Ownership Interest; ADP of the SNF	42.5
Oakway Operations LLC	6103212279	Organization	5% or Greater Direct Ownership Interest	15
Unknown party	2961978929	Individual	Indirect Ownership Interest	4.9
Unknown party	5698241651	Individual	Indirect Ownership Interest	4.9
Unknown party	3870069834	Individual	Indirect Ownership Interest	2.6
Unknown party	9133695190	Individual	Indirect Ownership Interest	2.6
Roth & Co, LLP	3173053162	Organization	ADP of the SNF	—
Clark City Sd Property Holdings, LLC	2365918323	Organization	ADP of the SNF	—
Legacy Healthcare Financial Services LLC	5799046132	Organization	ADP of the SNF	—

Bokf, NaPAC 0648188896
Organization1005% or Greater Security Interest; Operational/Managerial Control
Edward A DickesPAC 8325289663
IndividualOperational/Managerial Control; ADP of the SNF
Rachel MorehousePAC 7517433576
IndividualOperational/Managerial Control; ADP of the SNF
Chaim RajchenbachPAC 4284547977
IndividualOperational/Managerial Control; Managing Control - Governing Body
Menachem ShabatPAC 3072526219
IndividualOperational/Managerial Control; Managing Control - Governing Body
Doros Generation Trust U/A/D 1/3/12PAC 6901110428
Organization42.55% or Greater Direct Ownership Interest; ADP of the SNF
Gpn Family Trust U/A/D 4/28/08PAC 5294988994
Organization42.55% or Greater Direct Ownership Interest; ADP of the SNF
Oakway Operations LLCPAC 6103212279
Organization155% or Greater Direct Ownership Interest
Unknown partyPAC 2961978929
Individual4.9Indirect Ownership Interest
Unknown partyPAC 5698241651
Individual4.9Indirect Ownership Interest
Unknown partyPAC 3870069834
Individual2.6Indirect Ownership Interest
Unknown partyPAC 9133695190
Individual2.6Indirect Ownership Interest
Roth & Co, LLPPAC 3173053162
OrganizationADP of the SNF
Clark City Sd Property Holdings, LLCPAC 2365918323
OrganizationADP of the SNF
Legacy Healthcare Financial Services LLCPAC 5799046132
OrganizationADP of the SNF

Facility	Location	% Own.	HPRD	Ratings	Census	Flags
Avantara Clark City Clark City Sd Skilled Nursing Facility LLC 29 residents		Other disclo…	4.17	Ovr★★★★☆Stf★★☆☆☆Ins★★★★☆QM★★☆☆☆	29

Avantara Clark City
Clark City Sd Skilled Nursing Facility LLC
Other disclosed role29 res4.17 HPRD
Overall 4Staffing Staff 2

1 CMS ownership change record (showing 1)

Effective	Facility	Buyer	Seller	Side
07/01/2019	Avantara Clark City	Clark City Sd Skilled Nursing Facility LLC	Clark Care and Rehabilitation Center LLC	Buyer

07/01/2019
Avantara Clark City (Buyer)
Clark Care and Rehabilitation Center LLC → Clark City Sd Skilled Nursing Facility LLC

Related CMS associates

Name match to Clark City Sd Skilled Nursing Facility LLC in FEC filings. Similar names may appear—confirm on FEC.gov.