Cycle 1
Health 2025-03-07 · Fire 2025-03-07
8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Chicago, IL
Little Sisters Of The Poor
5-star overall rating with 3-star inspections with $9,110 in total fines with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
2325 North Lakewood Avenue, Chicago, IL
(773) 935-9600
Overall
5 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
76
Certified beds
Average residents
46
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2018-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.98
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.55
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
3.00
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
4.53
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.53
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.93
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.66
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
1.21
CMS adjusted RN staffing hours
Adjusted total hours
5.59
CMS adjusted total nurse staffing hours
Case-mix index
1.11
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,039
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
60.70
Composite VBP score used to determine payment impact.
Payment multiplier
1.0158
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
6.35
Baseline 29.41% · Performance 37.70% · Measure score 6.35 · Achievement 6.35 · Improvement 0
Adjusted total nurse staffing
5.78
Baseline 5.73 hours · Performance 4.72 hours · Measure score 5.78 · Achievement 5.78 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 4 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 4 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 6 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 14.29% |
8.2%
6.1 pts better
|
Numerator 26 · Denominator 182 |
| Staff flu vaccination coverage | 99.01% |
42%
57 pts better
|
Numerator 201 · Denominator 203 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
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 0.8 · Expected 1.4 · 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 0.5 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.5% |
89.6%
0.9 pts better
|
93.4%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 77.5% · Q2 83.3% · Q3 100.0% · Q4 100.0% · 4Q avg 90.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
91.6%
8.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.6% |
3.3%
0.3 pts worse
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 4.8% · Q3 0.0% · Q4 2.3% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 22.6% |
50.3%
27.7 pts better
|
11.4%
11.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.5% · Q2 22.0% · Q3 25.0% · Q4 16.3% · 4Q avg 22.6% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
6.5%
1.2 pts better
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 7.1% · Q3 9.3% · Q4 0.0% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.1% |
18.5%
8.4 pts better
|
19.6%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 9.5% · Q3 7.0% · Q4 11.4% · 4Q avg 10.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.1% |
22.8%
20.7 pts better
|
16.7%
14.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.8% · Q3 0.0% · Q4 2.7% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 1.2% |
0.1%
1.1 pts worse
|
0.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.9% · Q4 0.0% · 4Q avg 1.2% |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.2% |
17.2%
10 pts better
|
16.3%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 3.6% · Q3 12.2% · Q4 3.3% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.3% |
15.0%
2.7 pts better
|
14.9%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 7.5% · Q3 4.9% · Q4 16.3% · 4Q avg 12.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
1.1%
0.5 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.3% · Q4 0.0% · 4Q avg 0.6% · 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 | 22.3% |
21.3%
1 pts worse
|
19.8%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.2% · Q2 9.2% · Q3 27.4% · Q4 28.8% · 4Q avg 22.3% |
| Percentage of long-stay residents with pressure ulcers | 7.8% |
5.2%
2.6 pts worse
|
5.1%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 3.5% · Q3 6.5% · Q4 10.5% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 50.0% |
68.8%
18.8 pts worse
|
81.7%
31.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 50.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-08 · Fire 2024-02-08
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2023-01-06 · Fire 2023-01-06
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-07
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-03-24
F · Potential for more than minimal harm
2025-03-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-26
F · Potential for more than minimal harm
2025-03-07
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-03-20
F · Potential for more than minimal harm
2025-03-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-21
E · Potential for more than minimal harm
2025-03-07
K223 · Egress Deficiencies
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 2025-03-20
E · Potential for more than minimal harm
2025-03-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-20
F · Potential for more than minimal harm
2024-02-08
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2024-03-08
F · Potential for more than minimal harm
2024-02-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-08
F · Potential for more than minimal harm
2024-02-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-06
F · Potential for more than minimal harm
2024-02-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-16
E · Potential for more than minimal harm
2024-02-08
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-02-06
E · Potential for more than minimal harm
2024-02-08
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 2024-02-06
E · Potential for more than minimal harm
2024-02-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-06
E · Potential for more than minimal harm
2024-02-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-02-06
F · Potential for more than minimal harm
2023-01-06
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2023-03-22
F · Potential for more than minimal harm
2023-01-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-01-12
E · Potential for more than minimal harm
2023-01-06
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-01-16
E · Potential for more than minimal harm
2023-01-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-12
E · Potential for more than minimal harm
2023-01-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-01-12
Inspection history
Recent health citations
G · Actual harm
2025-05-01
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 2025-06-01
F · Potential for more than minimal harm
2025-03-07
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 2025-03-21
E · Potential for more than minimal harm
2025-03-07
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-04-24
E · Potential for more than minimal harm
2025-03-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-04
E · Potential for more than minimal harm
2025-03-07
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 2025-04-04
E · Potential for more than minimal harm
2025-03-07
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-03-07
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-07
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-04-01
G · Actual harm
2024-08-29
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 2024-09-23
F · Potential for more than minimal harm
2024-02-08
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 2024-02-27
D · Potential for more than minimal harm
2024-02-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-02-08
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-02-08
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2024-02-29
F · Potential for more than minimal harm
2023-01-06
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 2023-01-20
E · Potential for more than minimal harm
2023-01-06
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-01-20
E · Potential for more than minimal harm
2023-01-06
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2023-01-20
E · Potential for more than minimal harm
2023-01-06
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 2023-01-20
D · Potential for more than minimal harm
2023-01-06
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-01-20
D · Potential for more than minimal harm
2023-01-06
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 2023-01-20
D · Potential for more than minimal harm
2023-01-06
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 2023-01-20
D · Potential for more than minimal harm
2023-01-06
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-01-20
D · Potential for more than minimal harm
2023-01-06
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-01-20
Penalties and ownership
What sits behind the stars
$9,110
2025-03-07
Fine
Fine · fine $9,110
Fine
$0
2025-03-07
Payment Denial
Payment Denial · denial start 2025-05-27 · 5 days
5 day denial
Ownership
Mccanless, Claire
5% Or Greater Indirect Ownership Interest · Individual
Donnelly, Ann
Corporate Officer · Individual
Martin, Carolyn
Corporate Officer · Individual
Mccanless, Claire
Corporate Officer · Individual
Mccanless, Claire
W-2 Managing Employee · Individual
Nearby options
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#2
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1-star overall rating with 2-star inspections with abuse icon flag with $82,329 in total fines with 18 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Warren Barr Lincoln Park
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4-star overall rating with 3-star inspections with $125,108 in total fines with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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