Cycle 1
Health 2024-06-14 · Fire 2024-06-14
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Chicago, IL
St Joseph Village Of Chicago
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
Facility snapshot
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
Chain footprint
6 facilities
Chain averages 4 overall / 4 health / 4 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
Hours and turnover
RN hours / resident day
1.60
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.33
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.83
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
4.76
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.93
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
4.46
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
1.41
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
1.61
CMS adjusted RN staffing hours
Adjusted total hours
4.79
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
62%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,829
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.51
Composite VBP score used to determine payment impact.
Payment multiplier
0.9955
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.73
Baseline 17.67% · Performance 20.17% · Measure score 2.73 · Achievement 2.73 · Improvement 0
Healthcare-associated infections
3.53
Baseline 7.16% · Performance 6.78% · Measure score 3.53 · Achievement 3.53 · Improvement 1.24
Total nurse turnover
4.34
Baseline 68.85% · Performance 47.54% · Measure score 4.34 · Achievement 3.95 · Improvement 4.34
Adjusted total nurse staffing
6.41
Baseline 3.61 hours · Performance 4.90 hours · Measure score 6.41 · Achievement 6.41 · Improvement 5.46
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.62% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 225 · Observed rate 10.22% · Lower 95% interval 7.84% |
| Discharge to community | 54.19% |
50.57%
3.6 pts better
|
No Different than the National Rate · Eligible stays 222 · Observed rate 47.75% · Lower 95% interval 46.19% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.43% |
95.27%
4.2 pts better
|
Numerator 174 · Denominator 175 |
| Falls with major injury | 0.57% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 175 |
| Discharge self-care score | 62.83% |
53.69%
9.1 pts better
|
Numerator 71 · Denominator 113 |
| Discharge mobility score | 38.94% |
50.94%
12 pts worse
|
Numerator 44 · Denominator 113 |
| Pressure ulcers or injuries, new or worsened | 1.71% |
2.29%
0.6 pts better
|
Numerator 3 · Denominator 175 · Adjusted rate 1.56% |
| Healthcare-associated infections requiring hospitalization | 6.78% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 169 · Observed rate 6.51% · Lower 95% interval 3.96% |
| Staff COVID-19 vaccination coverage | 1.05% |
8.2%
7.1 pts worse
|
Numerator 2 · Denominator 190 |
| Staff flu vaccination coverage | 16.67% |
42%
25.3 pts worse
|
Numerator 18 · Denominator 108 |
| Discharge function score | 52.21% |
56.45%
4.2 pts worse
|
Numerator 59 · Denominator 113 |
| Transfer of health information to provider | 98.39% |
95.95%
2.4 pts better
|
Numerator 61 · Denominator 62 |
| Transfer of health information to patient | 97.85% |
96.28%
1.6 pts better
|
Numerator 91 · Denominator 93 |
| Resident COVID-19 vaccinations up to date | 23.58% |
25.2%
1.6 pts worse
|
Numerator 25 · Denominator 106 |
Quality measures
Resident outcomes and process scores
| 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 · Q1 95.7% · Q2 90.5% · Q3 100.0% · Q4 95.8% · 4Q avg 95.6% |
| 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 · 4Q avg 95.8% |
| 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 · Q1 0.0% · Q2 0.0% · Q3 4.3% · Q4 4.2% · 4Q avg 2.2% · Used in QM five-star |
| 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 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 · Q1 19.0% · Q3 4.8% · Q4 0.0% · 4Q avg 8.5% |
| 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 · Q1 4.3% · Q3 9.1% · Q4 4.3% · 4Q avg 6.9% |
| 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 · 4Q avg 21.2% · 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 | 0.0% |
17.2%
17.2 pts better
|
16.3%
16.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| 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 · Q3 4.5% · Q4 18.2% · 4Q avg 11.1% · 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 · Q4 0.0% · 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 · 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 | 34.6% |
21.3%
13.3 pts worse
|
19.8%
14.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 23.4% · 4Q avg 34.6% |
| 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 · Q1 4.9% · Q2 14.7% · Q3 12.6% · Q4 6.7% · 4Q avg 9.7% · Used in QM five-star |
| 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 · Q1 59.3% · Q2 72.3% · Q3 88.9% · Q4 95.3% · 4Q avg 78.6% |
| 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 · Adjusted 9.3% · Observed 9.0% · Expected 10.7% · Used in QM five-star |
| 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 · Q1 2.8% · Q2 2.5% · Q3 1.7% · Q4 0.8% · 4Q avg 1.9% · Used in QM five-star |
| 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 · 4Q avg 79.2% |
| 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 · Adjusted 20.9% · Observed 19.9% · Expected 22.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-26 · Fire 2023-05-26
11 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-07-29 · Fire 2022-07-29
4 health deficiencies
Top issue: Infection Control (2 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-06-14
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-07-11
F · Potential for more than minimal harm
2024-06-14
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-07-11
F · Potential for more than minimal harm
2024-06-14
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-07-11
F · Potential for more than minimal harm
2024-06-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-30
F · Potential for more than minimal harm
2024-06-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-06
F · Potential for more than minimal harm
2024-06-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-11
E · Potential for more than minimal harm
2024-06-14
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-07-11
D · Potential for more than minimal harm
2024-06-14
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 2024-07-11
F · Potential for more than minimal harm
2023-05-26
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-06-21
F · Potential for more than minimal harm
2023-05-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-07-05
F · Potential for more than minimal harm
2023-05-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-28
F · Potential for more than minimal harm
2023-05-26
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-06-16
F · Potential for more than minimal harm
2023-05-26
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-05-26
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-05-26
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-05-26
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-06-21
F · Potential for more than minimal harm
2022-07-29
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-08-19
F · Potential for more than minimal harm
2022-07-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-10-06
F · Potential for more than minimal harm
2022-07-29
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-01-24
E · Potential for more than minimal harm
2022-07-29
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 2022-08-19
E · Potential for more than minimal harm
2022-07-29
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-08-19
E · Potential for more than minimal harm
2022-07-29
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2022-08-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-09
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 2025-07-22
D · Potential for more than minimal harm
2024-08-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-16
D · Potential for more than minimal 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 2024-09-16
G · Actual harm
2024-06-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-11
G · Actual harm
2024-06-14
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 2024-07-11
F · Potential for more than minimal harm
2024-06-14
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 2024-07-11
E · Potential for more than minimal harm
2024-06-14
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 2024-07-11
E · Potential for more than minimal harm
2024-06-14
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 2024-07-11
D · Potential for more than minimal harm
2024-06-14
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-07-11
F · Potential for more than minimal harm
2023-05-26
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 2023-06-16
D · Potential for more than minimal harm
2023-05-26
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 2023-06-16
D · Potential for more than minimal harm
2023-05-26
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-05-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-05-26
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 2023-06-16
D · Potential for more than minimal harm
2023-05-26
F803 · Nutrition and Dietary Deficiencies
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
D · Potential for more than minimal harm
2023-05-26
F921 · Environmental Deficiencies
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
D · Potential for more than minimal harm
2023-04-29
F657 · Resident Assessment and Care Planning Deficiencies
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
E · Potential for more than minimal harm
2022-07-29
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-08-19
D · Potential for more than minimal harm
2022-07-29
F693 · Quality of Life and Care Deficiencies
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
B · Minimal harm
2022-07-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-19
Penalties and ownership
What sits behind the stars
Ownership
Amiano, Judy
Corporate Director · Individual
Amiano, Judy
Corporate Officer · Individual
Celerio, Brian
Operational/Managerial Control · Individual
Celerio, Brian
W-2 Managing Employee · Individual
Duren, Andrew
Corporate Director · Individual
Duren, Andrew
Corporate Officer · Individual
Noonan, Daniel
Corporate Director · Individual
Noonan, Daniel
Corporate Officer · Individual
Radke, Francis
Corporate Director · Individual
Radke, Francis
Corporate Officer · Individual
Stark, James
Corporate Director · Individual
Stark, James
Corporate Officer · Individual
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