Cycle 1
Health 2024-09-05 · Fire 2024-09-05
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Des Plaines, IL
Ascension Nazarethville Place
5-star overall rating with 5-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
300 North River Road, Des Plaines, IL
(847) 297-5900
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
68
Certified beds
Average residents
56
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ascension Living
Operator or chain grouping
Approved since
2015-12-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
19 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars
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
1.43
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.15
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.30
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.88
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.58
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.42
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
1.12
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.49
CMS adjusted RN staffing hours
Adjusted total hours
4.04
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
19%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
26%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,295
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.69
Composite VBP score used to determine payment impact.
Payment multiplier
0.9901
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
3.68
Performance 6.74% · Measure score 3.68 · Achievement 3.68 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
6.41
Baseline 52.94% · Performance 37.50% · Measure score 6.41 · Achievement 6.41 · Improvement 5
Adjusted total nurse staffing
0.93
Baseline 3.14 hours · Performance 3.34 hours · Measure score 0.93 · Achievement 0.93 · Improvement 0.26
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.68% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 41 · Observed rate 9.76% · Lower 95% interval 6.7% |
| Discharge to community | 34.28% |
50.57%
16.3 pts worse
|
No Different than the National Rate · Eligible stays 27 · Observed rate 18.52% · Lower 95% interval 20.51% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 84.38% |
95.27%
10.9 pts worse
|
Numerator 27 · Denominator 32 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 32 |
| Discharge self-care score | 32% |
53.69%
21.7 pts worse
|
Numerator 8 · Denominator 25 |
| Discharge mobility score | 24% |
50.94%
26.9 pts worse
|
Numerator 6 · Denominator 25 |
| Pressure ulcers or injuries, new or worsened | 3.13% |
2.29%
0.8 pts worse
|
Numerator 1 · Denominator 32 · Adjusted rate 2.37% |
| Healthcare-associated infections requiring hospitalization | 6.74% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 27 · Observed rate 3.7% · Lower 95% interval 3.27% |
| Staff COVID-19 vaccination coverage | 2.86% |
8.2%
5.3 pts worse
|
Numerator 2 · Denominator 70 |
| Staff flu vaccination coverage | 97.47% |
42%
55.5 pts better
|
Numerator 77 · Denominator 79 |
| Discharge function score | 28% |
56.45%
28.5 pts worse
|
Numerator 7 · Denominator 25 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
2.0
0.4 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 1.5 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
2.3
1.1 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 0.8 · Expected 1.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 57.3% |
89.6%
32.3 pts worse
|
93.4%
36.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 54.0% · Q2 57.9% · Q3 60.0% · Q4 57.7% · 4Q avg 57.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.2% |
91.6%
3.6 pts better
|
95.5%
0.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
3.3%
0.7 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 3.5% · Q3 5.5% · Q4 1.9% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 49.3% |
50.3%
1 pts better
|
11.4%
37.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 52.5% · Q2 46.3% · Q3 50.9% · Q4 46.9% · 4Q avg 49.3% |
| Percentage of long-stay residents who lose too much weight | 2.7% |
6.5%
3.8 pts better
|
5.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 4.2% · Q3 2.4% · Q4 2.6% · 4Q avg 2.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.9% |
18.5%
8.6 pts better
|
19.6%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 10.4% · Q3 10.9% · Q4 9.8% · 4Q avg 9.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.2% |
22.8%
9.6 pts better
|
16.7%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 16.3% · Q3 10.8% · Q4 6.2% · 4Q avg 13.2% · 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 | 17.2% |
17.2%
About the same
|
16.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.0% |
15.0%
About the same
|
14.9%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 11.6% · Q3 9.5% · Q4 18.4% · 4Q avg 15.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.1%
1.1 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.7%
1.2 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.9% |
21.3%
11.4 pts better
|
19.8%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 9.3% · Q3 13.6% · Q4 8.3% · 4Q avg 9.9% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
5.2%
1.9 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.5% · Q3 2.8% · Q4 1.5% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 9.9% |
68.8%
58.9 pts worse
|
81.7%
71.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 6.2% · Q3 15.8% · Q4 12.5% · 4Q avg 9.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.1% |
14.0%
3.9 pts better
|
12.0%
1.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.1% · Observed 9.5% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.3%
2.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 12.5% |
63.0%
50.5 pts worse
|
79.7%
67.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 12.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.6% |
26.2%
2.6 pts better
|
23.9%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.6% · Observed 21.4% · Expected 21.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-12 · Fire 2023-10-12
0 health deficiencies
No concentrated health issue counts in this cycle.
6 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-11-17 · Fire 2022-11-17
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-09-05
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-09-18
E · Potential for more than minimal harm
2024-09-05
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-09-18
E · Potential for more than minimal harm
2024-09-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-18
E · Potential for more than minimal harm
2024-09-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-18
D · Potential for more than minimal harm
2024-09-05
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-09-18
F · Potential for more than minimal harm
2023-10-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-23
E · Potential for more than minimal harm
2023-10-12
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-10-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-10-11
E · Potential for more than minimal harm
2023-10-12
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-10-11
E · Potential for more than minimal harm
2023-10-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-11
D · Potential for more than minimal harm
2023-10-12
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-10-23
F · Potential for more than minimal harm
2022-11-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-09
F · Potential for more than minimal harm
2022-11-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-12-09
E · Potential for more than minimal harm
2022-11-17
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-12-02
E · Potential for more than minimal harm
2022-11-17
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-12-02
E · Potential for more than minimal harm
2022-11-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-12-09
E · Potential for more than minimal harm
2022-11-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-09
E · Potential for more than minimal harm
2022-11-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-12-02
D · Potential for more than minimal harm
2022-11-17
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-12-09
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-31
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2026-01-07
D · Potential for more than minimal harm
2025-12-31
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 2026-01-07
D · Potential for more than minimal harm
2025-09-02
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-09-08
D · Potential for more than minimal harm
2024-09-05
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 2024-09-23
G · Actual harm
2022-11-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-12-13
Penalties and ownership
What sits behind the stars
Ownership
Presence Chicago Hospitals Network
5% Or Greater Indirect Ownership Interest · Organization
Presence Senior Services Chicagoland
5% Or Greater Direct Ownership Interest · Organization
Blake, Jean
Corporate Director · Individual
Dowd, Nancy
Corporate Director · Individual
Hagen, James
Corporate Director · Individual
Hugar, Joseph
Corporate Officer · Individual
Hugar, Joseph
W-2 Managing Employee · Individual
Jones, Lucia
Corporate Director · Individual
Kwiatkowski, Theresa
Corporate Director · Individual
Larson, John
Corporate Director · Individual
Mason, Marie
Corporate Director · Individual
Miller, Sallie
Corporate Director · Individual
Nichols, Phyllis
Corporate Director · Individual
Pankau, Lawrence
Corporate Director · Individual
Phillippe, Timothy
Corporate Director · Individual
Smith, Thomas
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Alden Des Plaines Rehab & Hc
Des Plaines, IL
3-star overall rating with 4-star inspections with $28,893 in total fines with 14 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Lee Manor
Des Plaines, IL
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Rivaya Care Of Des Plaines
Des Plaines, IL
1-star overall rating with 2-star inspections with $274,991 in total fines with 10 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
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