5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Chicago, IL
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
4021 West Belmont, Chicago, IL
(773) 328-5500
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
54
Certified beds
Average residents
50
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Franciscan Communities
Operator or chain grouping
Approved since
1989-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
1.60
Registered nurse staffing
LPN hours / resident day
0.33
Licensed practical nurse staffing
Aide hours / resident day
2.83
Nurse aide staffing
Weekend hours
4.46
Weekend nurse staffing
RN turnover
62%
Annual RN turnover
Total nurse turnover
53%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.6% |
89.6%
6 pts better
|
93.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.8% |
91.6%
4.2 pts better
|
95.5%
0.3 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
3.3%
1.1 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
50.3%
50.3 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 8.5% |
6.5%
2 pts worse
|
5.4%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.9% |
18.5%
11.6 pts better
|
19.6%
12.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 21.2% |
22.8%
1.6 pts better
|
16.7%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 0.0% |
17.2%
17.2 pts better
|
16.3%
16.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.1% |
15.0%
3.9 pts better
|
14.9%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.6% |
21.3%
13.3 pts worse
|
19.8%
14.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 9.7% |
5.2%
4.5 pts worse
|
5.1%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.6% |
68.8%
9.8 pts better
|
81.7%
3.1 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.3% |
14.0%
4.7 pts better
|
12.0%
2.7 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
2.3%
0.4 pts better
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 79.2% |
63.0%
16.2 pts better
|
79.7%
0.5 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.9% |
26.2%
5.3 pts better
|
23.9%
3 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Pharmacy Service (2 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Top issue: Quality of Life and Care (7 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Infection Control (2 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-07-11
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-07-11
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-07-11
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-30
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-06
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-11
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-07-11
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 2024-07-11
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-06-21
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-07-05
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-28
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-06-16
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-06-16
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-06-16
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-06-16
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-06-21
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-08-19
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-10-06
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-01-24
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 2022-08-19
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-08-19
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2022-08-19
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-22
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-16
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-16
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-11
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-11
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-11
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-07-11
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 2024-07-11
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-07-11
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-06-16
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-06-16
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-06-16
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-16
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 2023-06-16
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 2023-06-16
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-06-16
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 2023-05-16
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-08-19
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-08-19
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-19
Penalties and ownership
Corporate Director · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
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