Cycle 1
Health 2025-02-06 · Fire 2025-02-06
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Chicago, IL
Mercy Circle
5-star overall rating with 5-star inspections with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
3659 West 99th Street, Chicago, IL
(773) 253-3600
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
23
Certified beds
Average residents
22
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2015-01-10
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
1.65
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.16
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.92
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
4.72
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.81
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
4.13
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.92
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.65
CMS adjusted RN staffing hours
Adjusted total hours
4.72
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
39%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,207
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
58.80
Composite VBP score used to determine payment impact.
Payment multiplier
1.0140
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.03
Baseline 20.83% · Performance 19.56% · Measure score 4.03 · Achievement 4.03 · Improvement 2.83
Healthcare-associated infections
7.31
Baseline 7.47% · Performance 5.65% · Measure score 7.31 · Achievement 7.31 · Improvement 6.86
Total nurse turnover
6.3
Baseline 38.23% · Performance 37.93% · Measure score 6.3 · Achievement 6.3 · Improvement 0
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 | 9.96% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 175 · Observed rate 6.86% · Lower 95% interval 7.5% |
| Discharge to community | 72.6% |
50.57%
22 pts better
|
Better than the National Rate · Eligible stays 182 · Observed rate 72.53% · Lower 95% interval 65.98% |
| Medicare spending per beneficiary | 1.16 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 105 · Denominator 105 |
| Falls with major injury | 4.76% |
0.77%
4 pts worse
|
Numerator 5 · Denominator 105 |
| Discharge self-care score | 59.04% |
53.69%
5.4 pts better
|
Numerator 49 · Denominator 83 |
| Discharge mobility score | 67.47% |
50.94%
16.5 pts better
|
Numerator 56 · Denominator 83 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 105 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.65% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 106 · Observed rate 1.89% · Lower 95% interval 3.3% |
| Staff COVID-19 vaccination coverage | 6.85% |
8.2%
1.3 pts worse
|
Numerator 10 · Denominator 146 |
| Staff flu vaccination coverage | 68.71% |
42%
26.7 pts better
|
Numerator 101 · Denominator 147 |
| Discharge function score | 67.47% |
56.45%
11 pts better
|
Numerator 56 · Denominator 83 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 24 · Denominator 24 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 79 · Denominator 79 |
| Resident COVID-19 vaccinations up to date | 21.57% |
25.2%
3.6 pts worse
|
Numerator 11 · Denominator 51 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.8% |
3.3%
5.5 pts worse
|
3.3%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.2% |
50.3%
47.1 pts better
|
11.4%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.2% |
| Percentage of long-stay residents who lose too much weight | 15.0% |
6.5%
8.5 pts worse
|
5.4%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.0% |
18.5%
11.5 pts worse
|
19.6%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.0% |
| 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.0% |
15.0%
5 pts worse
|
14.9%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.0% · 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 · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.2% |
21.3%
3.1 pts better
|
19.8%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.2% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
5.2%
5.2 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.6% |
68.8%
27.8 pts better
|
81.7%
14.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.2% · Q2 97.4% · Q3 95.3% · Q4 97.6% · 4Q avg 96.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.9% |
14.0%
8.1 pts better
|
12.0%
6.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.9% · Observed 5.0% · Expected 9.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.4% |
2.3%
1.1 pts worse
|
1.6%
1.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.4% · Q3 3.1% · Q4 3.3% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.5% |
63.0%
28.5 pts better
|
79.7%
11.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.2% |
26.2%
6 pts better
|
23.9%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.2% · Observed 15.8% · Expected 18.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-26 · Fire 2024-01-26
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2023-03-31 · Fire 2023-03-31
9 health deficiencies
Top issue: Infection Control (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-26
F · Potential for more than minimal harm
2025-02-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-21
F · Potential for more than minimal harm
2025-02-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-02-21
E · Potential for more than minimal harm
2025-02-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-21
F · Potential for more than minimal harm
2024-01-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-14
F · Potential for more than minimal harm
2023-03-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-17
F · Potential for more than minimal harm
2023-03-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-17
C · Minimal harm
2023-03-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-17
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-18
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-09-18
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 2025-10-09
D · Potential for more than minimal harm
2025-09-18
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 2025-10-09
D · Potential for more than minimal harm
2025-02-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-20
F · Potential for more than minimal harm
2024-01-26
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 2024-02-14
F · Potential for more than minimal harm
2024-01-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-26
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 2024-02-14
D · Potential for more than minimal harm
2024-01-26
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 2024-02-14
D · Potential for more than minimal harm
2023-08-05
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 2023-08-19
F · Potential for more than minimal harm
2023-03-31
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 2023-04-15
F · Potential for more than minimal harm
2023-03-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-15
F · Potential for more than minimal harm
2023-03-31
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2023-04-15
F · Potential for more than minimal harm
2023-03-31
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2023-04-15
D · Potential for more than minimal harm
2023-03-31
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-04-15
D · Potential for more than minimal harm
2023-03-31
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 2023-04-15
D · Potential for more than minimal harm
2023-03-31
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-15
C · Minimal harm
2023-03-31
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2023-04-15
Penalties and ownership
What sits behind the stars
Ownership
Sisters Of Mercy Of The Americas West Midwest Community Inc
5% Or Greater Direct Ownership Interest · Organization
Frikker, Judith
Corporate Director · Individual
Frikker, Judith
Corporate Officer · Individual
Hinz, Margaret
Corporate Director · Individual
Klosowski, Maria
Corporate Director · Individual
Lachowicz, Frances
W-2 Managing Employee · Individual
Miller, Anne
Corporate Director · Individual
Reicks, Laura
Corporate Director · Individual
Reicks, Laura
Corporate Officer · Individual
Sanders, Susan
Corporate Director · Individual
Sanders, Susan
Corporate Officer · Individual
Trinity Continuing Care Services
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
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1-star overall rating with 2-star inspections with $351,352 in total fines with 19 recent health deficiencies
#2
Warren Barr Oak Lawn
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4-star overall rating with 4-star inspections with 2 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Aliya On 87th
Chicago, IL
2-star overall rating with 1-star inspections with $231,981 in total fines with 23 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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