11 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Chicago, IL
1-star overall rating with 2-star inspections with $88,128 in total fines with 11 recent health deficiencies
2242 North Kedzie, Chicago, IL
(773) 486-7700
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
222
Certified beds
Average residents
202
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pavilion Healthcare
Operator or chain grouping
Approved since
1994-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 3 overall / 3 health / 2 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
0.39
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.60
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.11
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.11
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
0.99
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
2.64
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.29
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.30
CMS adjusted RN staffing hours
Adjusted total hours
2.39
CMS adjusted total nurse staffing hours
Case-mix index
1.78
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
22%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Program rank
9,231
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.35
Composite VBP score used to determine payment impact.
Payment multiplier
0.9834
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 19.29% · Performance 22.52% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0.76
Baseline 7.53% · Performance 7.61% · Measure score 0.76 · Achievement 0.76 · Improvement 0
Total nurse turnover
8.28
Baseline 36.27% · Performance 29.84% · Measure score 8.28 · Achievement 8.28 · Improvement 5.13
Adjusted total nurse staffing
0.70
Baseline 1.75 hours · Performance 2.23 hours · Measure score 0.70 · Achievement 0 · Improvement 0.70
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.49% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 139 · Observed rate 12.95% · Lower 95% interval 8.23% |
| Discharge to community | 27.68% |
50.57%
22.9 pts worse
|
Worse than the National Rate · Eligible stays 59 · Observed rate 13.56% · Lower 95% interval 19.05% |
| Medicare spending per beneficiary | 1.29 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 142 · Denominator 142 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 142 |
| Discharge self-care score | 33.7% |
53.69%
20 pts worse
|
Numerator 31 · Denominator 92 |
| Discharge mobility score | 42.39% |
50.94%
8.5 pts worse
|
Numerator 39 · Denominator 92 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 142 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.61% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 88 · Observed rate 10.23% · Lower 95% interval 4.73% |
| Staff COVID-19 vaccination coverage | 0.49% |
8.2%
7.7 pts worse
|
Numerator 1 · Denominator 203 |
| Staff flu vaccination coverage | 41.26% |
42%
0.7 pts worse
|
Numerator 85 · Denominator 206 |
| Discharge function score | 35.87% |
56.45%
20.6 pts worse
|
Numerator 33 · Denominator 92 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 46 · Denominator 46 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 21.88% |
25.2%
3.3 pts worse
|
Numerator 14 · Denominator 64 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.0
0.2 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.5 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
2.3
About the same
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.1 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 77.7% |
89.6%
11.9 pts worse
|
93.4%
15.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 69.5% · Q2 67.9% · Q3 89.4% · Q4 84.4% · 4Q avg 77.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.5% |
91.6%
6.9 pts better
|
95.5%
3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
3.3%
1.4 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 2.1% · Q3 2.1% · Q4 2.1% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 99.9% |
50.3%
49.6 pts worse
|
11.4%
88.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 99.5% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.9% |
| Percentage of long-stay residents who lose too much weight | 7.6% |
6.5%
1.1 pts worse
|
5.4%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 7.1% · Q3 9.3% · Q4 8.4% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.2% |
18.5%
9.3 pts better
|
19.6%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 7.5% · Q3 7.1% · Q4 11.9% · 4Q avg 9.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 26.3% |
22.8%
3.5 pts worse
|
16.7%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 24.4% · Q3 26.4% · Q4 27.3% · 4Q avg 26.3% · 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 | 3.2% |
17.2%
14 pts better
|
16.3%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 1.1% · Q3 5.0% · Q4 2.9% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.5% |
15.0%
6.5 pts better
|
14.9%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 5.3% · Q3 10.4% · Q4 8.9% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.1%
0.8 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.0% · Q3 0.5% · Q4 0.0% · 4Q avg 0.3% · 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 | 28.8% |
21.3%
7.5 pts worse
|
19.8%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.4% · Q2 28.5% · Q3 31.2% · Q4 25.1% · 4Q avg 28.8% |
| Percentage of long-stay residents with pressure ulcers | 1.9% |
5.2%
3.3 pts better
|
5.1%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 0.7% · Q3 3.4% · Q4 0.6% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 43.3% |
68.8%
25.5 pts worse
|
81.7%
38.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 28.3% · Q3 48.1% · Q4 69.6% · 4Q avg 43.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.4% |
14.0%
3.6 pts better
|
12.0%
1.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.4% · Observed 11.1% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.8% |
2.3%
0.5 pts worse
|
1.6%
1.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.7% · Q3 3.7% · Q4 3.4% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 61.1% |
63.0%
1.9 pts worse
|
79.7%
18.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 61.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.7% |
26.2%
1.5 pts worse
|
23.9%
3.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.7% · Observed 30.9% · Expected 26.6% · Used in QM five-star |
Survey summary
Top issue: Pharmacy Service (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Quality of Life and Care (9 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Quality of Life and Care (14 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-09-05
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-05
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 2025-09-05
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-09-05
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 2025-09-05
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-09-05
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-05
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-09-05
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-09-05
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-06-05
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-06-05
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-26
Health
Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid.
Corrected 2025-01-29
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-01-29
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-26
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-26
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-02
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-09-19
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-09-19
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 2024-09-19
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-19
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-19
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2024-09-19
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-09-19
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-09-19
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 2024-09-19
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-19
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-09-19
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-09-19
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 2024-09-19
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-09-19
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-30
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-24
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-24
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-10
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-10
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-01-10
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-01-10
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-01-10
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-01-10
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-01-10
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-10
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-10
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-11-10
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 2023-11-10
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-10
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-11-10
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-11-10
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-11-10
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-10
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-10
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-10
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-07-20
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-20
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-07-20
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 2023-07-20
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-12
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-05-12
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-05-12
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-05-12
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-03-14
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-14
Penalties and ownership
Fine · fine $19,474
Fine
Fine · fine $47,886
Fine
Payment Denial · denial start 2024-09-06 · 26 days
26 day denial
Fine · fine $20,768
Fine
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Nearby options
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