Cycle 1
Health 2024-03-07 · Fire 2024-03-07
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Melrose Park, IL
Gottlieb Memorial Hospital
5-star overall rating with 5-star inspections with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
701 West North Avenue, Melrose Park, IL
(708) 450-4908
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
32
Certified beds
Average residents
24
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Trinity Health
Operator or chain grouping
Approved since
1985-06-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 3 overall / 3 health / 4 staffing / 4 quality stars
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
3.93
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
2.23
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
6.16
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
3.93
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
5.94
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
3.67
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.33
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
4.07
CMS adjusted RN staffing hours
Adjusted total hours
6.37
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,072
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
60.24
Composite VBP score used to determine payment impact.
Payment multiplier
1.0154
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.85
Baseline 19.91% · Performance 20.11% · Measure score 2.85 · Achievement 2.85 · Improvement 0
Healthcare-associated infections
9.20
Baseline 4.47% · Performance 5.08% · Measure score 9.20 · Achievement 9.20 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
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 | 12.15% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 393 · Observed rate 13.74% · Lower 95% interval 9.96% |
| Discharge to community | 78.51% |
50.57%
27.9 pts better
|
Better than the National Rate · Eligible stays 380 · Observed rate 72.63% · Lower 95% interval 73.9% |
| Medicare spending per beneficiary | 0.6 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 98.09% |
95.27%
2.8 pts better
|
Numerator 257 · Denominator 262 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 262 |
| Discharge self-care score | 46.43% |
53.69%
7.3 pts worse
|
Numerator 104 · Denominator 224 |
| Discharge mobility score | 31.25% |
50.94%
19.7 pts worse
|
Numerator 70 · Denominator 224 |
| Pressure ulcers or injuries, new or worsened | 0.38% |
2.29%
1.9 pts better
|
Numerator 1 · Denominator 262 · Adjusted rate 0.62% |
| Healthcare-associated infections requiring hospitalization | 5.08% |
7.12%
2 pts better
|
No Different than the National Rate · Eligible stays 241 · Observed rate 2.9% · Lower 95% interval 3.04% |
| Staff COVID-19 vaccination coverage | 32.47% |
8.2%
24.3 pts better
|
Numerator 25 · Denominator 77 |
| Staff flu vaccination coverage | 81.63% |
42%
39.6 pts better
|
Numerator 40 · Denominator 49 |
| Discharge function score | 37.5% |
56.45%
19 pts worse
|
Numerator 84 · Denominator 224 |
| Transfer of health information to provider | 99.47% |
95.95%
3.5 pts better
|
Numerator 186 · Denominator 187 |
| Transfer of health information to patient | 96% |
96.28%
0.3 pts worse
|
Numerator 72 · Denominator 75 |
| Resident COVID-19 vaccinations up to date | 27.91% |
25.2%
2.7 pts better
|
Numerator 36 · Denominator 129 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
68.8%
30.5 pts better
|
81.7%
17.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.7% · Q2 99.3% · Q3 99.3% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.2% |
14.0%
7.8 pts better
|
12.0%
5.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.2% · Observed 5.9% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
2.3%
2 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.9% |
63.0%
32.9 pts better
|
79.7%
16.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.3% |
26.2%
0.1 pts worse
|
23.9%
2.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.3% · Observed 24.4% · Expected 22.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-14 · Fire 2023-04-14
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-11-10 · Fire 2021-11-10
3 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-03-07
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-03-13
F · Potential for more than minimal harm
2024-03-07
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-03-19
F · Potential for more than minimal harm
2024-03-07
K907 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure medical gas and vacuum systems have documented maintenance programs.
Corrected 2024-03-11
E · Potential for more than minimal harm
2024-03-07
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-03-14
F · Potential for more than minimal harm
2023-04-14
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-04-18
E · Potential for more than minimal harm
2023-04-14
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-04-18
E · Potential for more than minimal harm
2021-11-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-11-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-03-07
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-03-21
D · Potential for more than minimal harm
2024-03-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-03-21
D · Potential for more than minimal harm
2024-03-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-21
C · Minimal harm
2024-03-07
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-03-21
D · Potential for more than minimal harm
2023-04-14
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-04-29
F · Potential for more than minimal harm
2021-11-10
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 2021-11-22
E · Potential for more than minimal harm
2021-11-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-11-24
E · Potential for more than minimal harm
2021-11-10
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2021-11-22
Penalties and ownership
What sits behind the stars
Ownership
Cunningham, Joy
Corporate Director · Individual
Early, Elizabeth
Corporate Director · Individual
Early, Elizabeth
Corporate Officer · Individual
Early, Elizabeth
W-2 Managing Employee · Individual
Freeman, Richard
Corporate Officer · Individual
Gomez, Tad
Corporate Director · Individual
Healey, Lori
Corporate Director · Individual
Kolawole, Adenrele
Corporate Officer · Individual
Loyola University Health System
5% Or Greater Indirect Ownership Interest · Organization
Lukasick, Melissa
Corporate Officer · Individual
Monice, Pierre
Corporate Director · Individual
Pekar, Maria
Corporate Officer · Individual
Pratt, Antoinette
Operational/Managerial Control · Individual
Rappis, Jill
Corporate Officer · Individual
Schwartz, Marc
Corporate Officer · Individual
Trinity Health Corporation
5% Or Greater Indirect Ownership Interest · Organization
Wojcik, Eva
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Bria Of Elmwood Park
Elmwood Park, IL
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $400,219 in total fines with 26 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#2
Oak Park Oasis
Oak Park, IL
1-star overall rating with 2-star inspections with abuse icon flag with $163,101 in total fines with 23 recent health deficiencies with 22 fire-safety deficiencies in the latest cycle
#3
Berkeley Nursing & Rehab Center
Oak Park, IL
3-star overall rating with 3-star inspections with $311,943 in total fines with 6 recent health deficiencies with 18 fire-safety deficiencies in the latest cycle
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