Cycle 1
Health 2024-08-09 · Fire 2024-08-09
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Chicago, IL
Community First Medical Center
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
5645 West Addison Street, Chicago, IL
(773) 282-7000
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
66
Certified beds
Average residents
15
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1985-11-12
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
4.07
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
1.49
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
5.56
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
4.07
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
4.99
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
3.52
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.22
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
4.01
CMS adjusted RN staffing hours
Adjusted total hours
5.48
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
6%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
13%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
875
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
62.59
Composite VBP score used to determine payment impact.
Payment multiplier
1.0175
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.88
Baseline 20.31% · Performance 21.02% · Measure score 0.88 · Achievement 0.88 · Improvement 0
Healthcare-associated infections
7.9
Baseline 5.93% · Performance 5.47% · Measure score 7.9 · Achievement 7.9 · Improvement 4.37
Total nurse turnover
10
Baseline 22.58% · Performance 17.24% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.55% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 451 · Observed rate 11.31% · Lower 95% interval 9.41% |
| Discharge to community | 71.6% |
50.57%
21 pts better
|
Better than the National Rate · Eligible stays 368 · Observed rate 70.11% · Lower 95% interval 67.09% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 94.33% |
95.27%
0.9 pts worse
|
Numerator 233 · Denominator 247 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 247 |
| Discharge self-care score | 29.44% |
53.69%
24.2 pts worse
|
Numerator 58 · Denominator 197 |
| Discharge mobility score | 53.81% |
50.94%
2.9 pts better
|
Numerator 106 · Denominator 197 |
| Pressure ulcers or injuries, new or worsened | 0.81% |
2.29%
1.5 pts better
|
Numerator 2 · Denominator 247 · Adjusted rate 0.84% |
| Healthcare-associated infections requiring hospitalization | 5.47% |
7.12%
1.7 pts better
|
No Different than the National Rate · Eligible stays 209 · Observed rate 3.35% · Lower 95% interval 3.47% |
| Staff COVID-19 vaccination coverage | 26.55% |
8.2%
18.4 pts better
|
Numerator 262 · Denominator 987 |
| Staff flu vaccination coverage | 90.13% |
42%
48.1 pts better
|
Numerator 703 · Denominator 780 |
| Discharge function score | 42.64% |
56.45%
13.8 pts worse
|
Numerator 84 · Denominator 197 |
| Transfer of health information to provider | 99% |
95.95%
3 pts better
|
Numerator 199 · Denominator 201 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 46 · Denominator 46 |
| Resident COVID-19 vaccinations up to date | 65.69% |
25.2%
40.5 pts better
|
Numerator 90 · Denominator 137 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.9% |
68.8%
25.1 pts better
|
81.7%
12.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.0% · Q2 94.2% · Q3 95.3% · Q4 92.8% · 4Q avg 93.9% |
| 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 8.1% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
2.3%
0.9 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.5% · Q3 0.7% · Q4 0.9% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 73.1% |
63.0%
10.1 pts better
|
79.7%
6.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 73.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.6% |
26.2%
0.6 pts better
|
23.9%
1.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.6% · Observed 24.7% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-01 · Fire 2023-09-01
8 health deficiencies
Top issue: Infection Control (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-10-07 · Fire 2022-10-07
12 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-19
F · Potential for more than minimal harm
2024-08-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-15
F · Potential for more than minimal harm
2024-08-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-08-15
E · Potential for more than minimal harm
2024-08-09
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-11-08
F · Potential for more than minimal harm
2023-09-01
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-07
F · Potential for more than minimal harm
2023-09-01
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2023-09-07
F · Potential for more than minimal harm
2023-09-01
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-11-01
F · Potential for more than minimal harm
2023-09-01
K907 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure medical gas and vacuum systems have documented maintenance programs.
Corrected 2023-10-06
F · Potential for more than minimal harm
2023-09-01
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2023-10-01
E · Potential for more than minimal harm
2023-09-01
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Not marked corrected
F · Potential for more than minimal harm
2022-10-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-08
F · Potential for more than minimal harm
2022-10-07
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-04-26
E · Potential for more than minimal harm
2022-10-07
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Not marked corrected
E · Potential for more than minimal harm
2022-10-07
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 2022-11-30
C · Minimal harm
2022-10-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-22
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-08-09
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 2024-08-16
E · Potential for more than minimal harm
2024-08-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-08-09
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-08-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-16
F · Potential for more than minimal harm
2023-09-01
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 2023-09-14
F · Potential for more than minimal harm
2023-09-01
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 2023-09-14
F · Potential for more than minimal harm
2023-09-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-14
E · Potential for more than minimal harm
2023-09-01
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 2023-09-14
D · Potential for more than minimal harm
2023-09-01
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 2023-09-14
D · Potential for more than minimal harm
2023-09-01
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-09-14
D · Potential for more than minimal harm
2023-09-01
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-09-14
D · Potential for more than minimal harm
2023-09-01
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-09-14
D · Potential for more than minimal harm
2023-03-22
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 2023-03-29
D · Potential for more than minimal harm
2023-03-22
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-03-29
D · Potential for more than minimal harm
2023-03-22
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 2023-03-29
D · Potential for more than minimal harm
2023-03-22
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 2023-03-29
F · Potential for more than minimal harm
2022-10-07
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 2022-10-10
F · Potential for more than minimal harm
2022-10-07
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-10-07
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-10-10
E · Potential for more than minimal harm
2022-10-07
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-10-07
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 2022-10-14
D · Potential for more than minimal harm
2022-10-07
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-10-07
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 2022-10-14
D · Potential for more than minimal harm
2022-10-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-14
Penalties and ownership
What sits behind the stars
Ownership
Muckelrath, Rick
5% Or Greater Direct Ownership Interest · Individual
Fitzmaurice, Dennis
Corporate Officer · Individual
Fitzmaurice, Dennis
W-2 Managing Employee · Individual
Green, Edward
5% Or Greater Direct Ownership Interest · Individual
Green, Edward
Corporate Director · Individual
Muckelrath, Rick
Corporate Director · Individual
Pankau, Elizabeth
Corporate Officer · Individual
Nearby options
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3-star overall rating with 3-star inspections with $25,750 in total fines with 9 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Central Nursing Home
Chicago, IL
1-star overall rating with 2-star inspections with $57,261 in total fines with 17 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Pearl Of Montclare, The
Chicago, IL
2-star overall rating with 2-star inspections with $124,281 in total fines with 16 recent health deficiencies
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