Cycle 1
Health 2025-04-24 · Fire 2025-04-24
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Northbrook, IL
Brandel Health And Rehab
5-star overall rating with 5-star inspections with 2 recent health deficiencies
2155 Pfingsten Road, Northbrook, IL
(847) 480-6350
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
102
Certified beds
Average residents
72
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Covenant Living
Operator or chain grouping
Approved since
1985-10-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 4 overall / 4 health / 4 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
0.87
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.53
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.58
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.99
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.73
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.69
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.88
CMS adjusted RN staffing hours
Adjusted total hours
4.00
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
38%
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
3,217
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.42
Composite VBP score used to determine payment impact.
Payment multiplier
0.9986
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.95
Baseline 22.95% · Performance 20.31% · Measure score 3.95 · Achievement 2.41 · Improvement 3.95
Healthcare-associated infections
0.92
Baseline 5.41% · Performance 7.56% · Measure score 0.92 · Achievement 0.92 · Improvement 0
Total nurse turnover
9.27
Baseline 41.38% · Performance 25.81% · Measure score 9.27 · Achievement 9.27 · Improvement 8.92
Adjusted total nurse staffing
4.04
Baseline 3.90 hours · Performance 4.23 hours · Measure score 4.04 · Achievement 4.04 · Improvement 1.22
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.93% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 241 · Observed rate 7.88% · Lower 95% interval 6.99% |
| Discharge to community | 63.03% |
50.57%
12.5 pts better
|
Better than the National Rate · Eligible stays 219 · Observed rate 58.45% · Lower 95% interval 56.2% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 164 · Denominator 164 |
| Falls with major injury | 1.83% |
0.77%
1.1 pts worse
|
Numerator 3 · Denominator 164 |
| Discharge self-care score | 29.75% |
53.69%
23.9 pts worse
|
Numerator 36 · Denominator 121 |
| Discharge mobility score | 27.27% |
50.94%
23.7 pts worse
|
Numerator 33 · Denominator 121 |
| Pressure ulcers or injuries, new or worsened | 3.05% |
2.29%
0.8 pts worse
|
Numerator 5 · Denominator 164 · Adjusted rate 3.02% |
| Healthcare-associated infections requiring hospitalization | 7.56% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 137 · Observed rate 6.57% · Lower 95% interval 4.93% |
| Staff COVID-19 vaccination coverage | 5.41% |
8.2%
2.8 pts worse
|
Numerator 4 · Denominator 74 |
| Staff flu vaccination coverage | 44.06% |
42%
2.1 pts better
|
Numerator 63 · Denominator 143 |
| Discharge function score | 28.1% |
56.45%
28.4 pts worse
|
Numerator 34 · Denominator 121 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 30 · Denominator 30 |
| Transfer of health information to patient | 99.02% |
96.28%
2.7 pts better
|
Numerator 101 · Denominator 102 |
| Resident COVID-19 vaccinations up to date | 17.05% |
25.2%
8.1 pts worse
|
Numerator 15 · Denominator 88 |
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 1.7 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
2.3
1.4 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.1% |
89.6%
4.5 pts better
|
93.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.5% · Q2 94.3% · Q3 94.0% · Q4 91.5% · 4Q avg 94.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 66.7% |
91.6%
24.9 pts worse
|
95.5%
28.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 66.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.8% |
3.3%
4.5 pts worse
|
3.3%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 7.5% · Q3 12.0% · Q4 6.8% · 4Q avg 7.8% · 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% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 5.6% |
6.5%
0.9 pts better
|
5.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.3% · Q3 9.8% · Q4 6.2% · 4Q avg 5.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.0% |
18.5%
8.5 pts better
|
19.6%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 9.3% · Q3 12.2% · Q4 8.2% · 4Q avg 10.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.9% |
22.8%
0.1 pts worse
|
16.7%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 18.8% · Q3 25.0% · Q4 28.2% · 4Q avg 22.9% · 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 | 20.3% |
17.2%
3.1 pts worse
|
16.3%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.4% |
15.0%
3.4 pts worse
|
14.9%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 17.5% · Q3 21.1% · Q4 30.2% · 4Q avg 18.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.2% |
1.1%
1.1 pts worse
|
1.0%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 1.0% · Q3 1.2% · Q4 2.5% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.1% |
1.7%
3.4 pts worse
|
1.7%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 7.5% · Q3 4.0% · Q4 3.4% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.7% |
21.3%
5.4 pts worse
|
19.8%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.9% · Q2 23.7% · Q3 33.2% · Q4 22.1% · 4Q avg 26.7% |
| Percentage of long-stay residents with pressure ulcers | 8.0% |
5.2%
2.8 pts worse
|
5.1%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 12.2% · Q3 3.2% · Q4 6.7% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.2% |
68.8%
21.4 pts better
|
81.7%
8.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.9% · Q2 87.7% · Q3 87.8% · Q4 93.0% · 4Q avg 90.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.2% |
14.0%
5.8 pts better
|
12.0%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.2% · Observed 7.4% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
2.3%
0.7 pts better
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.3% · Q3 2.4% · Q4 1.4% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.7% |
63.0%
24.7 pts better
|
79.7%
8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.6% |
26.2%
1.4 pts worse
|
23.9%
3.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.6% · Observed 25.9% · Expected 22.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-28 · Fire 2024-03-28
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Cycle 3
Health 2023-01-12 · Fire 2023-01-12
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-03-28
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-05-13
F · Potential for more than minimal harm
2024-03-28
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2024-05-13
F · Potential for more than minimal harm
2024-03-28
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-04-29
F · Potential for more than minimal harm
2024-03-28
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2024-05-03
F · Potential for more than minimal harm
2024-03-28
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-04-29
F · Potential for more than minimal harm
2024-03-28
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-05-13
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-09-12
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-12-01
F · Potential for more than minimal harm
2025-04-24
F729 · Nursing and Physician Services Deficiencies
Health
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Corrected 2025-05-08
G · Actual harm
2024-08-15
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 2024-08-26
Penalties and ownership
What sits behind the stars
Ownership
Berg, Kathryn
W-2 Managing Employee · Individual
Covenant Living Communities & Services
Operational/Managerial Control · Organization
Creaney, Janet
Corporate Officer · Individual
Cunliffe, Terri
Operational/Managerial Control · Individual
Cunliffe, Terri
Corporate Officer · Individual
Cunliffe, Terri
W-2 Managing Employee · Individual
Flewellen, Lorene
Corporate Officer · Individual
Justie, Jeannie
Operational/Managerial Control · Individual
Justie, Jeannie
W-2 Managing Employee · Individual
Malzahn, Elizabeth
W-2 Managing Employee · Individual
Manlove, Matt
Corporate Officer · Individual
Sager, Hilde
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Citadel of Northbrook, The
Northbrook, IL
4-star overall rating with 4-star inspections with $25,126 in total fines with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Glenview Terrace
Glenview, IL
2-star overall rating with 2-star inspections with abuse icon flag with 7 recent health deficiencies
#3
Elevate Care Abington
Glenview, IL
5-star overall rating with 4-star inspections with $10,033 in total fines with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
Jump out