Cycle 1
Health 2025-01-24 · Fire 2025-01-24
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Chicago, IL
Admiral At The Lake, The
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
933 West Foster Avenue, Chicago, IL
(773) 654-5121
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
36
Certified beds
Average residents
29
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2013-10-01
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.75
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.74
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.70
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
4.19
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.56
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.50
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.79
CMS adjusted RN staffing hours
Adjusted total hours
4.41
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,995
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
52.41
Composite VBP score used to determine payment impact.
Payment multiplier
1.0069
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.12% · Performance 22.03% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.98
Baseline 6.86% · Performance 6.35% · Measure score 4.98 · Achievement 4.98 · Improvement 2.26
Total nurse turnover
5.99
Baseline 30.00% · Performance 39.22% · Measure score 5.99 · Achievement 5.99 · Improvement 0
Adjusted total nurse staffing
10
Baseline 5.28 hours · Performance 6.3 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.17% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 88 · Observed rate 5.68% · Lower 95% interval 6.42% |
| Discharge to community | 65.2% |
50.57%
14.6 pts better
|
Better than the National Rate · Eligible stays 77 · Observed rate 63.64% · Lower 95% interval 54.82% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 96.97% |
95.27%
1.7 pts better
|
Numerator 64 · Denominator 66 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 66 |
| Discharge self-care score | 67.44% |
53.69%
13.8 pts better
|
Numerator 29 · Denominator 43 |
| Discharge mobility score | 53.49% |
50.94%
2.6 pts better
|
Numerator 23 · Denominator 43 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 66 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.35% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 51 · Observed rate 3.92% · Lower 95% interval 3.62% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 62.79% |
56.45%
6.3 pts better
|
Numerator 27 · Denominator 43 |
| Transfer of health information to provider | 90.91% |
95.95%
5 pts worse
|
Numerator 20 · Denominator 22 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 27 · Denominator 27 |
| Resident COVID-19 vaccinations up to date | 86.49% |
25.2%
61.3 pts better
|
Numerator 32 · Denominator 37 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.5 |
2.0
1.5 pts worse
|
1.9
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 3.4 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
2.3
1.9 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.3 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.6%
10.4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
91.6%
8.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 9.8% |
3.3%
6.5 pts worse
|
3.3%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 8.7% · Q3 13.0% · Q4 10.0% · 4Q avg 9.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
50.3%
50.3 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 15.1% |
6.5%
8.6 pts worse
|
5.4%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · 4Q avg 15.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.6% |
18.5%
10.9 pts better
|
19.6%
12 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 10.0% · Q3 10.0% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.5% |
22.8%
11.3 pts better
|
16.7%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 23.3% |
17.2%
6.1 pts worse
|
16.3%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.4% |
15.0%
1.4 pts worse
|
14.9%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.0% · 4Q avg 16.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.4% |
1.1%
2.3 pts worse
|
1.0%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.4% |
21.3%
11.9 pts better
|
19.8%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · 4Q avg 9.4% |
| Percentage of long-stay residents with pressure ulcers | 20.7% |
5.2%
15.5 pts worse
|
5.1%
15.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 29.0% · Q3 21.7% · 4Q avg 20.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
68.8%
31.2 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.1% |
14.0%
6.9 pts better
|
12.0%
4.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.1% · Observed 6.8% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.9% |
2.3%
2.6 pts worse
|
1.6%
3.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q3 5.0% · Q4 3.6% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.3% |
63.0%
27.3 pts better
|
79.7%
10.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.7% |
26.2%
6.5 pts worse
|
23.9%
8.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.7% · Observed 30.5% · Expected 22.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-09 · Fire 2024-02-09
10 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
4 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Cycle 3
Health 2023-03-02 · Fire 2023-03-02
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-24
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-02-07
F · Potential for more than minimal harm
2025-01-24
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-01-24
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-02-07
F · Potential for more than minimal harm
2025-01-24
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-02-07
F · Potential for more than minimal harm
2025-01-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-07
E · Potential for more than minimal harm
2025-01-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-07
C · Minimal harm
2025-01-24
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-02-07
C · Minimal harm
2025-01-24
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-02-07
F · Potential for more than minimal harm
2024-02-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-01
F · Potential for more than minimal harm
2024-02-09
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-03-01
E · Potential for more than minimal harm
2024-02-09
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-03-01
E · Potential for more than minimal harm
2024-02-09
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-03-01
F · Potential for more than minimal harm
2023-03-02
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-03-31
F · Potential for more than minimal harm
2023-03-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-03
F · Potential for more than minimal harm
2023-03-02
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-03-31
F · Potential for more than minimal harm
2023-03-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-31
F · Potential for more than minimal harm
2023-03-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-31
E · Potential for more than minimal harm
2023-03-02
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-03-31
D · Potential for more than minimal harm
2023-03-02
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-03-31
Inspection history
Recent health citations
G · Actual harm
2025-06-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-26
D · Potential for more than minimal harm
2025-06-06
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-06-26
F · Potential for more than minimal harm
2025-01-24
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-02-07
F · Potential for more than minimal harm
2025-01-24
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-07
F · Potential for more than minimal harm
2025-01-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-07
E · Potential for more than minimal harm
2025-01-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-24
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-24
F688 · Quality of Life and Care Deficiencies
Health
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 2025-02-07
D · Potential for more than minimal harm
2025-01-24
F761 · Pharmacy Service Deficiencies
Health
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 2025-02-07
F · Potential for more than minimal harm
2024-02-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-03-01
E · Potential for more than minimal harm
2024-02-09
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-03-01
E · Potential for more than minimal harm
2024-02-09
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-03-01
E · Potential for more than minimal harm
2024-02-09
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-09
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-09
F761 · Pharmacy Service Deficiencies
Health
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 2024-03-01
D · Potential for more than minimal harm
2024-02-09
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-09
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2024-03-01
F · Potential for more than minimal harm
2023-03-02
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-03-24
E · Potential for more than minimal harm
2023-03-02
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-03-24
E · Potential for more than minimal harm
2023-03-02
F761 · Pharmacy Service Deficiencies
Health
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 2023-03-24
E · Potential for more than minimal harm
2023-03-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-24
D · Potential for more than minimal harm
2023-03-02
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-03-24
D · Potential for more than minimal harm
2023-03-02
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-24
Penalties and ownership
What sits behind the stars
Ownership
Bransfield, Joan
Corporate Director · Individual
Churchill, Daniel
Corporate Officer · Individual
Churchill, Daniel
W-2 Managing Employee · Individual
Clarke, Charles
Corporate Director · Individual
Clarke, Charles
Corporate Officer · Individual
Dubovick, Chaim
W-2 Managing Employee · Individual
Geigler, Nadia
Operational/Managerial Control · Individual
Geigler, Nadia
Corporate Officer · Individual
Geigler, Nadia
W-2 Managing Employee · Individual
Hasten, Andrea
Corporate Director · Individual
Hasten, Andrea
Corporate Officer · Individual
Kelly, Sean
Corporate Director · Individual
Shields, Jordan
Corporate Director · Individual
Stitzer, Carol
Corporate Director · Individual
Traynor, Michael
Corporate Director · Individual
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