Cycle 1
Health 2025-04-03 · Fire 2025-04-03
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Chicago, IL
Birchwood Plaza
4-star overall rating with 4-star inspections with 8 recent health deficiencies
1426 West Birchwood, Chicago, IL
(773) 274-4405
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
200
Certified beds
Average residents
148
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Marquis Health Services
Operator or chain grouping
Approved since
1985-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
81 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 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
0.71
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.20
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.01
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
2.91
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
0.91
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
2.84
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.58
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.59
CMS adjusted RN staffing hours
Adjusted total hours
2.42
CMS adjusted total nurse staffing hours
Case-mix index
1.64
Higher values indicate more complex resident acuity
RN turnover
19%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
28%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,309
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.33
Composite VBP score used to determine payment impact.
Payment multiplier
0.9876
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.65
Baseline 21.39% · Performance 18.35% · Measure score 6.65 · Achievement 6.65 · Improvement 6.47
Healthcare-associated infections
0
Baseline 8.17% · Performance 8.46% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.43
Baseline 31.43% · Performance 37.38% · Measure score 6.43 · Achievement 6.43 · Improvement 0
Adjusted total nurse staffing
0.25
Baseline 2.18 hours · Performance 2.45 hours · Measure score 0.25 · Achievement 0 · Improvement 0.25
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.38% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 101 · Observed rate 8.91% · Lower 95% interval 6.75% |
| Discharge to community | 42.08% |
50.57%
8.5 pts worse
|
No Different than the National Rate · Eligible stays 66 · Observed rate 33.33% · Lower 95% interval 29.93% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 80 · Denominator 80 |
| Falls with major injury | 1.25% |
0.77%
0.5 pts worse
|
Numerator 1 · Denominator 80 |
| Discharge self-care score | 78.33% |
53.69%
24.6 pts better
|
Numerator 47 · Denominator 60 |
| Discharge mobility score | 60% |
50.94%
9.1 pts better
|
Numerator 36 · Denominator 60 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 80 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.46% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 60 · Observed rate 11.67% · Lower 95% interval 4.91% |
| Staff COVID-19 vaccination coverage | 12.66% |
8.2%
4.5 pts better
|
Numerator 20 · Denominator 158 |
| Staff flu vaccination coverage | 72.96% |
42%
31 pts better
|
Numerator 116 · Denominator 159 |
| Discharge function score | 75% |
56.45%
18.5 pts better
|
Numerator 45 · Denominator 60 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 22 · Denominator 22 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 20 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 50% |
25.2%
24.8 pts better
|
Numerator 25 · Denominator 50 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.0
0.1 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.4 · Expected 1.4 · 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 0.9 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
89.6%
8.5 pts better
|
93.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.2% · Q2 97.2% · Q3 98.6% · Q4 99.3% · 4Q avg 98.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.0% |
91.6%
6.4 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.3%
1.7 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.7% · Q3 0.7% · Q4 2.7% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 99.6% |
50.3%
49.3 pts worse
|
11.4%
88.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 99.3% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of long-stay residents who lose too much weight | 3.3% |
6.5%
3.2 pts better
|
5.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 3.2% · Q3 2.3% · Q4 2.3% · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 4.1% |
18.5%
14.4 pts better
|
19.6%
15.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.8% · Q3 3.8% · Q4 5.1% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.2% |
22.8%
2.6 pts better
|
16.7%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 20.0% · Q3 18.6% · Q4 21.3% · 4Q avg 20.2% · 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 | 11.8% |
17.2%
5.4 pts better
|
16.3%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 13.6% · Q3 5.5% · Q4 16.7% · 4Q avg 11.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.5% |
15.0%
0.5 pts better
|
14.9%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.4% · Q2 16.5% · Q3 10.8% · Q4 16.1% · 4Q avg 14.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.9% |
1.1%
0.8 pts worse
|
1.0%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 1.2% · Q3 1.8% · Q4 2.2% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.9% |
1.7%
1.2 pts worse
|
1.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 2.2% · Q3 3.5% · Q4 2.2% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.4% |
21.3%
6.1 pts worse
|
19.8%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.3% · Q2 29.6% · Q3 24.4% · Q4 23.4% · 4Q avg 27.4% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
5.2%
About the same
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 5.5% · Q3 4.7% · Q4 5.0% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.4% |
68.8%
15.6 pts better
|
81.7%
2.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 81.8% · Q2 90.0% · Q3 88.9% · Q4 73.1% · 4Q avg 84.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.7% |
14.0%
4.3 pts better
|
12.0%
2.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.7% · Observed 10.0% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.2% |
2.3%
2.9 pts worse
|
1.6%
3.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 9.1% · Q3 8.3% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 59.5% |
63.0%
3.5 pts worse
|
79.7%
20.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 59.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.4% |
26.2%
4.8 pts better
|
23.9%
2.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.4% · Observed 25.0% · Expected 27.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-08 · Fire 2024-03-08
11 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-06-02 · Fire 2023-06-02
9 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-03
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 2025-05-13
E · Potential for more than minimal harm
2025-04-03
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 2025-05-13
D · Potential for more than minimal harm
2025-04-03
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-05-13
D · Potential for more than minimal harm
2025-04-03
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-05-13
D · Potential for more than minimal harm
2025-04-03
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 2025-05-13
D · Potential for more than minimal harm
2025-04-03
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-05-13
D · Potential for more than minimal harm
2025-04-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-13
B · Minimal harm
2025-04-03
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2025-05-13
E · Potential for more than minimal harm
2024-12-26
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 2025-01-23
E · Potential for more than minimal harm
2024-12-26
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 2025-01-23
F · Potential for more than minimal harm
2024-03-08
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 2024-04-11
F · Potential for more than minimal harm
2024-03-08
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-04-11
D · Potential for more than minimal harm
2024-03-08
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 2024-04-11
D · Potential for more than minimal harm
2024-03-08
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-04-11
D · Potential for more than minimal harm
2024-03-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-11
D · Potential for more than minimal harm
2024-03-08
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 2024-04-11
D · Potential for more than minimal harm
2024-03-08
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2024-04-11
D · Potential for more than minimal harm
2024-03-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-11
B · Minimal harm
2024-03-08
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2024-04-11
G · Actual harm
2023-09-28
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 2023-10-23
F · Potential for more than minimal harm
2023-06-02
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 2023-06-23
E · Potential for more than minimal harm
2023-06-02
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 2023-06-23
E · Potential for more than minimal harm
2023-06-02
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 2023-06-23
D · Potential for more than minimal harm
2023-06-02
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-06-23
D · Potential for more than minimal harm
2023-06-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-23
D · Potential for more than minimal harm
2023-06-02
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2023-06-23
D · Potential for more than minimal harm
2023-06-02
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2023-06-23
B · Minimal harm
2023-06-02
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2023-06-08
Penalties and ownership
What sits behind the stars
Ownership
Kohn 2020 Descendants' Trust
5% Or Greater Direct Ownership Interest · Organization
Kohn 2020 Family Trust
5% Or Greater Direct Ownership Interest · Organization
Kohn, Charlotte
Operational/Managerial Control · Individual
Kohn, Charlotte
Corporate Director · Individual
Peddinghaus, Wolf
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Chicago, IL
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#2
Waterford Care Center, The
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3-star overall rating with 3-star inspections with 12 recent health deficiencies
#3
Lakefront Nursing & Rehab Ctr
Chicago, IL
5-star overall rating with 4-star inspections with $13,729 in total fines with 8 recent health deficiencies
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