Cycle 1
Health 2025-08-21 · Fire 2024-08-09
10 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Lemont, IL
Franciscan Village
3-star overall rating with 3-star inspections with $22,260 in total fines with 10 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
1270 Franciscan Drive, Lemont, IL
(630) 243-3500
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
127
Certified beds
Average residents
100
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Franciscan Communities
Operator or chain grouping
Approved since
1991-04-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 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
1.35
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.48
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.34
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
4.17
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.83
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.72
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.93
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
1.24
CMS adjusted RN staffing hours
Adjusted total hours
3.82
CMS adjusted total nurse staffing hours
Case-mix index
1.49
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,561
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.76
Composite VBP score used to determine payment impact.
Payment multiplier
0.9968
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.13
Baseline 20.96% · Performance 20.91% · Measure score 1.13 · Achievement 1.13 · Improvement 0
Healthcare-associated infections
6.87
Baseline 5.49% · Performance 5.78% · Measure score 6.87 · Achievement 6.87 · Improvement 0
Total nurse turnover
7.20
Baseline 55.28% · Performance 34.26% · Measure score 7.20 · Achievement 7.20 · Improvement 6.41
Adjusted total nurse staffing
2.31
Baseline 3.89 hours · Performance 3.73 hours · Measure score 2.31 · Achievement 2.31 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.71% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 472 · Observed rate 10.17% · Lower 95% interval 8.85% |
| Discharge to community | 55.25% |
50.57%
4.7 pts better
|
No Different than the National Rate · Eligible stays 441 · Observed rate 49.66% · Lower 95% interval 49.33% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 91.08% |
95.27%
4.2 pts worse
|
Numerator 286 · Denominator 314 |
| Falls with major injury | 0.32% |
0.77%
0.5 pts better
|
Numerator 1 · Denominator 314 |
| Discharge self-care score | 26.8% |
53.69%
26.9 pts worse
|
Numerator 67 · Denominator 250 |
| Discharge mobility score | 13.6% |
50.94%
37.3 pts worse
|
Numerator 34 · Denominator 250 |
| Pressure ulcers or injuries, new or worsened | 4.14% |
2.29%
1.8 pts worse
|
Numerator 13 · Denominator 314 · Adjusted rate 3.24% |
| Healthcare-associated infections requiring hospitalization | 5.78% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 286 · Observed rate 4.2% · Lower 95% interval 3.6% |
| Staff COVID-19 vaccination coverage | 0.82% |
8.2%
7.4 pts worse
|
Numerator 3 · Denominator 364 |
| Staff flu vaccination coverage | 2.9% |
42%
39.1 pts worse
|
Numerator 4 · Denominator 138 |
| Discharge function score | 19.6% |
56.45%
36.9 pts worse
|
Numerator 49 · Denominator 250 |
| Transfer of health information to provider | 93.75% |
95.95%
2.2 pts worse
|
Numerator 135 · Denominator 144 |
| Transfer of health information to patient | 99.12% |
96.28%
2.8 pts better
|
Numerator 112 · Denominator 113 |
| Resident COVID-19 vaccinations up to date | 19.48% |
25.2%
5.7 pts worse
|
Numerator 30 · Denominator 154 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
2.0
1 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
2.3
1.6 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.6%
10.4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 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 who have depressive symptoms | 2.2% |
50.3%
48.1 pts better
|
11.4%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 1.4% · Q3 1.5% · Q4 3.0% · 4Q avg 2.2% |
| Percentage of long-stay residents who lose too much weight | 8.1% |
6.5%
1.6 pts worse
|
5.4%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 10.6% · Q3 4.1% · Q4 5.0% · 4Q avg 8.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.4% |
18.5%
3.1 pts better
|
19.6%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 17.0% · Q3 16.3% · Q4 11.9% · 4Q avg 15.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.7% |
22.8%
9.1 pts better
|
16.7%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 15.8% · Q3 10.8% · Q4 16.1% · 4Q avg 13.7% · 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 need for help with daily activities has increased | 9.4% |
15.0%
5.6 pts better
|
14.9%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 4.8% · Q3 2.3% · Q4 12.8% · 4Q avg 9.4% · 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 | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 27.6% |
21.3%
6.3 pts worse
|
19.8%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 29.8% · Q3 33.1% · Q4 22.2% · 4Q avg 27.6% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
5.2%
1.1 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 3.4% · Q3 2.7% · Q4 4.1% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.4% |
68.8%
26.6 pts better
|
81.7%
13.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.2% · Q2 95.2% · Q3 96.5% · Q4 96.5% · 4Q avg 95.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.5% |
14.0%
4.5 pts better
|
12.0%
2.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.5% · Observed 8.6% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
2.3%
1.6 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.7% · Q3 0.6% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.5% |
63.0%
31.5 pts better
|
79.7%
14.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.3% |
26.2%
2.1 pts worse
|
23.9%
4.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.3% · Observed 26.5% · Expected 22.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-09 · Fire 2023-10-19
9 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-10-19 · Fire 2022-09-09
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-09
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2024-08-27
F · Potential for more than minimal harm
2024-08-09
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-12-05
F · Potential for more than minimal harm
2024-08-09
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 2024-08-30
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 2024-08-29
F · Potential for more than minimal harm
2024-08-09
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-09-20
E · Potential for more than minimal harm
2024-08-09
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-08-28
E · Potential for more than minimal harm
2024-08-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-28
F · Potential for more than minimal harm
2023-10-19
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-11-04
F · Potential for more than minimal harm
2023-10-19
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Not marked corrected
F · Potential for more than minimal harm
2023-10-19
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-01-19
E · Potential for more than minimal harm
2023-10-19
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 2023-11-03
E · Potential for more than minimal harm
2023-10-19
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-11-03
C · Minimal harm
2023-10-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-03
F · Potential for more than minimal harm
2022-09-09
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-10-13
F · Potential for more than minimal harm
2022-09-09
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Not marked corrected
F · Potential for more than minimal harm
2022-09-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-13
F · Potential for more than minimal harm
2022-09-09
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-10-13
F · Potential for more than minimal harm
2022-09-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-10-13
F · Potential for more than minimal harm
2022-09-09
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-10-13
F · Potential for more than minimal harm
2022-09-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-13
E · Potential for more than minimal harm
2022-09-09
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-10-13
E · Potential for more than minimal harm
2022-09-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-10-13
Inspection history
Recent health citations
G · Actual harm
2025-08-21
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 2025-09-08
F · Potential for more than minimal harm
2025-08-21
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 2025-09-08
E · Potential for more than minimal harm
2025-08-21
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 2025-09-08
E · Potential for more than minimal harm
2025-08-21
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2025-09-08
E · Potential for more than minimal harm
2025-08-21
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-09-08
E · Potential for more than minimal harm
2025-08-21
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-08-21
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 2025-09-08
D · Potential for more than minimal harm
2025-08-21
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-08-21
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-08-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-08
G · Actual harm
2024-08-09
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-08-26
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 2024-08-26
E · Potential for more than minimal harm
2024-08-09
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 2024-08-26
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 2024-09-19
D · Potential for more than minimal harm
2024-08-09
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-08-09
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-08-09
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-08-09
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-08-09
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
E · Potential for more than minimal harm
2023-10-19
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 2023-11-14
E · Potential for more than minimal harm
2023-10-19
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-11-14
E · Potential for more than minimal harm
2023-10-19
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 2023-11-14
E · Potential for more than minimal harm
2023-10-19
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-11-14
D · Potential for more than minimal harm
2023-10-19
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-11-14
D · Potential for more than minimal harm
2023-10-19
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-11-14
D · Potential for more than minimal harm
2023-10-19
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-11-14
D · Potential for more than minimal harm
2023-10-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-11-14
D · Potential for more than minimal harm
2023-10-19
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-11-14
Penalties and ownership
What sits behind the stars
$22,260
2025-08-21
Fine
Fine · fine $22,260
Fine
$0
2024-08-09
Payment Denial
Payment Denial · denial start 2024-08-30 · 20 days
20 day denial
Ownership
Franciscan Sisters Of Chicago Services Corporation
5% Or Greater Direct Ownership Interest · Organization
Burda, Diana
Operational/Managerial Control · Individual
Miranda, Heintje
Operational/Managerial Control · Individual
Parkhill, Roberta
Corporate Officer · Individual
Ramirez-Justin, Andrea
Corporate Director · Individual
Ramirez-Justin, Andrea
Corporate Officer · Individual
Rosenberger, Robert
Corporate Officer · Individual
Shearer, Tracy
Corporate Officer · Individual
Stark, James
Corporate Director · Individual
Stark, James
Corporate Officer · Individual
Umanskiy, Regina
Corporate Director · Individual
Umanskiy, Regina
Corporate Officer · Individual
Veal-Prom, Nicole
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Lemont Nursing & Rehab Center
Lemont, IL
2-star overall rating with 3-star inspections with 16 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Aliya Of Palos Park
Palos Park, IL
1-star overall rating with 2-star inspections with $365,884 in total fines with 19 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Victorian Village Hlth & Well
Homer Glen, IL
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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