8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Chicago, IL
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
4538 North Beacon, Chicago, IL
(773) 275-7200
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
0 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
143
Certified beds
Average residents
0
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
1993-11-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
85 facilities
Chain averages 3 overall / 3 health / 3 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
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
27%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Program rank
8,240
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.41
Composite VBP score used to determine payment impact.
Payment multiplier
0.9845
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 20.56% · Performance 21.36% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.96
Baseline 9.92% · Performance 7.72% · Measure score 3.96 · Achievement 0 · Improvement 3.96
Total nurse turnover
6.28
Baseline 43.48% · Performance 38.03% · Measure score 6.28 · Achievement 6.28 · Improvement 2.43
Adjusted total nurse staffing
0.72
Baseline 2.3 hours · Performance 2.73 hours · Measure score 0.72 · Achievement 0 · Improvement 0.72
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.28% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 51 · Observed rate 3.92% · Lower 95% interval 5.65% |
| Discharge to community | 39.9% |
50.57%
10.7 pts worse
|
No Different than the National Rate · Eligible stays 38 · Observed rate 23.68% · Lower 95% interval 24.61% |
| Medicare spending per beneficiary | 1.57 |
1.02
0.6 pts worse
|
|
| Drug regimen review with follow-up | 98.28% |
95.27%
3 pts better
|
Numerator 57 · Denominator 58 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 58 |
| Discharge self-care score | 20% |
53.69%
33.7 pts worse
|
Numerator 5 · Denominator 25 |
| Discharge mobility score | 32% |
50.94%
18.9 pts worse
|
Numerator 8 · Denominator 25 |
| Pressure ulcers or injuries, new or worsened | 3.45% |
2.29%
1.2 pts worse
|
Numerator 2 · Denominator 58 · Adjusted rate 2.38% |
| Healthcare-associated infections requiring hospitalization | 7.72% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 32 · Observed rate 12.5% · Lower 95% interval 3.68% |
| 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 | 53.49% |
42%
11.5 pts better
|
Numerator 46 · Denominator 86 |
| Discharge function score | 32% |
56.45%
24.5 pts worse
|
Numerator 8 · Denominator 25 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 30 · Denominator 30 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 47.83% |
25.2%
22.6 pts better
|
Numerator 11 · Denominator 23 |
Quality measures
| 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 1.8 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
2.3
0.3 pts better
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.9 · Expected 1.6 · 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 100.0% · Q2 100.0% · Q3 100.0% · Q4 92.6% · 4Q avg 98.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.7% |
91.6%
7.1 pts better
|
95.5%
3.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
3.3%
2 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 2.5% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 92.1% |
50.3%
41.8 pts worse
|
11.4%
80.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 90.7% · Q2 89.6% · Q3 93.2% · Q4 94.7% · 4Q avg 92.1% |
| Percentage of long-stay residents who lose too much weight | 5.0% |
6.5%
1.5 pts better
|
5.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 5.4% · Q3 6.8% · Q4 3.8% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 3.9% |
18.5%
14.6 pts better
|
19.6%
15.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 2.6% · Q3 1.3% · Q4 7.5% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.4% |
22.8%
9.4 pts better
|
16.7%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 14.6% · Q3 10.2% · Q4 16.0% · 4Q avg 13.4% · 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 | 3.8% |
17.2%
13.4 pts better
|
16.3%
12.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.4% · Q3 2.9% · Q4 8.4% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.5% |
15.0%
8.5 pts better
|
14.9%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 9.1% · Q3 3.2% · Q4 7.4% · 4Q avg 6.5% · 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 2.7% · Q2 2.5% · Q3 1.2% · Q4 1.1% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.7%
1.4 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.2% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.8% |
21.3%
11.5 pts better
|
19.8%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 6.0% · Q3 11.1% · Q4 14.1% · 4Q avg 9.8% |
| Percentage of long-stay residents with pressure ulcers | 7.6% |
5.2%
2.4 pts worse
|
5.1%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 9.2% · Q3 4.5% · Q4 6.9% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
68.8%
30.2 pts better
|
81.7%
17.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 96.0% · 4Q avg 99.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.5% |
14.0%
3.5 pts worse
|
12.0%
5.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.5% · Observed 24.3% · Expected 15.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 8.8% |
2.3%
6.5 pts worse
|
1.6%
7.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 8.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 52.2% |
63.0%
10.8 pts worse
|
79.7%
27.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 52.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.6% |
26.2%
2.4 pts worse
|
23.9%
4.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.6% · Observed 37.8% · Expected 31.5% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Top issue: Pharmacy Service (4 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Quality of Life and Care (6 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-03-20
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-05-07
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-03-20
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-20
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-03-20
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-20
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-04-17
Fire Safety
Have an enclosure around a vertical opening shaft.
Not marked corrected
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-20
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-02-14
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-09
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 2024-02-08
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 2024-02-08
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-08
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-02-08
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-02-08
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-05-15
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2023-05-03
Fire Safety
Have an enclosure around a vertical opening shaft.
Not marked corrected
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-07-05
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-12
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-05-03
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-05-03
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-05-15
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-19
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-17
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-05-03
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-06-12
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-05-03
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-05-03
Inspection history
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-14
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-14
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 2025-03-14
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-03-14
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-03-14
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-03-14
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-14
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2025-03-14
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-19
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-08-19
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-02-16
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-02-13
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 2024-02-13
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-02-13
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-02-12
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-02-12
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-02-13
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-02-13
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-02-15
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2023-12-08
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2023-12-08
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-12-08
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-08
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-06-26
Health
Post nurse staffing information every day.
Corrected 2023-05-04
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-05-04
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-05-04
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-05-04
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-05-04
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-05-04
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-04
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-04
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 2023-05-04
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-04
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-14
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-04-04
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
W-2 Managing Employee · Individual
Corporate Officer · Individual
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