6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Lindenhurst, IL
5-star overall rating with 4-star inspections with $35,902 in total fines with 6 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
1055 East Grand Avenue, Lindenhurst, IL
(847) 356-5900
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
120
Certified beds
Average residents
84
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Franciscan Communities
Operator or chain grouping
Approved since
1989-02-02
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
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
1.31
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.71
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.24
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
4.25
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
2.01
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.74
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
0.12
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.26
CMS adjusted RN staffing hours
Adjusted total hours
4.10
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
42%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Program rank
6,094
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.02
Composite VBP score used to determine payment impact.
Payment multiplier
0.9881
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 18.43% · Performance 21.58% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.67
Baseline 4.29% · Performance 6.74% · Measure score 3.67 · Achievement 3.67 · Improvement 0
Total nurse turnover
7.07
Baseline 56.57% · Performance 34.78% · Measure score 7.07 · Achievement 7.07 · Improvement 6.37
Adjusted total nurse staffing
2.87
Baseline 3.88 hours · Performance 3.89 hours · Measure score 2.87 · Achievement 2.87 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.73% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 730 · Observed rate 11.51% · Lower 95% interval 9.96% |
| Discharge to community | 62.37% |
50.57%
11.8 pts better
|
Better than the National Rate · Eligible stays 704 · Observed rate 58.66% · Lower 95% interval 58.48% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.08% |
95.27%
3.8 pts better
|
Numerator 433 · Denominator 437 |
| Falls with major injury | 0.69% |
0.77%
0.1 pts better
|
Numerator 3 · Denominator 437 |
| Discharge self-care score | 54.33% |
53.69%
0.6 pts better
|
Numerator 182 · Denominator 335 |
| Discharge mobility score | 42.69% |
50.94%
8.2 pts worse
|
Numerator 143 · Denominator 335 |
| Pressure ulcers or injuries, new or worsened | 4.12% |
2.29%
1.8 pts worse
|
Numerator 18 · Denominator 437 · Adjusted rate 4.14% |
| Healthcare-associated infections requiring hospitalization | 6.74% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 423 · Observed rate 6.38% · Lower 95% interval 4.58% |
| Staff COVID-19 vaccination coverage | 22.03% |
8.2%
13.8 pts better
|
Numerator 76 · Denominator 345 |
| Staff flu vaccination coverage | 14.81% |
42%
27.2 pts worse
|
Numerator 44 · Denominator 297 |
| Discharge function score | 44.48% |
56.45%
12 pts worse
|
Numerator 149 · Denominator 335 |
| Transfer of health information to provider | 97.89% |
95.95%
1.9 pts better
|
Numerator 93 · Denominator 95 |
| Transfer of health information to patient | 99.32% |
96.28%
3 pts better
|
Numerator 290 · Denominator 292 |
| Resident COVID-19 vaccinations up to date | 6.34% |
25.2%
18.9 pts worse
|
Numerator 13 · Denominator 205 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
2.0
1.2 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0 |
2.3
2.3 pts better
|
1.8
1.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0 · Observed 0 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.3% |
89.6%
7.7 pts better
|
93.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.6% · Q2 97.8% · Q3 97.9% · Q4 100.0% · 4Q avg 97.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.0% |
91.6%
6.4 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.5% |
3.3%
2.8 pts better
|
3.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.8% |
50.3%
46.5 pts better
|
11.4%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.3% · Q3 0.0% · Q4 11.6% · 4Q avg 3.8% |
| Percentage of long-stay residents who lose too much weight | 2.8% |
6.5%
3.7 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 5.6% · Q4 6.1% · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.7% |
18.5%
9.8 pts better
|
19.6%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 10.8% · Q3 7.9% · Q4 8.6% · 4Q avg 8.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.7% |
22.8%
18.1 pts better
|
16.7%
12 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 5.9% · Q3 6.2% · Q4 0.0% · 4Q avg 4.7% · 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 need for help with daily activities has increased | 4.1% |
15.0%
10.9 pts better
|
14.9%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 2.8% · Q3 5.3% · Q4 0.0% · 4Q avg 4.1% · 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 · 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 a urinary tract infection | 0.6% |
1.7%
1.1 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.3% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.5% |
21.3%
1.2 pts worse
|
19.8%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 34.8% · Q3 19.8% · Q4 21.3% · 4Q avg 22.5% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
5.2%
1.1 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 3.5% · Q3 3.0% · Q4 1.5% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.3% |
68.8%
23.5 pts better
|
81.7%
10.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 82.0% · Q2 90.3% · Q3 98.4% · Q4 99.0% · 4Q avg 92.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.4% |
14.0%
0.6 pts better
|
12.0%
1.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.4% · Observed 11.7% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
2.3%
1.7 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.3% · Q2 0.8% · Q3 0.4% · Q4 0.8% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.3% |
63.0%
17.3 pts better
|
79.7%
0.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.5% |
26.2%
5.7 pts better
|
23.9%
3.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.5% · Observed 19.0% · Expected 22.1% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (7 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Fire safety
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-02-14
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-02-14
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-27
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-03-17
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-02-14
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-03-17
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 2025-02-14
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-14
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 2025-02-14
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-03-11
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2024-03-07
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-09
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-02-26
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-11
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-03-07
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-03-05
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-22
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-02-23
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2023-05-12
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2023-05-12
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-05-12
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-05-12
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-12
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-05-12
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-05-12
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-12
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-05-12
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-05-12
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-05-12
Inspection history
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2025-11-25
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-11-25
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-12
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-12
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-02-12
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-02-12
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-03
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-03
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 2024-03-03
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-03
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-03-03
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2024-03-03
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-03-03
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-03-03
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-03-03
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-03-03
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2024-03-03
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-19
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-04-21
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-04-21
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-21
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-21
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-21
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-21
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-04-21
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-04-21
Penalties and ownership
Fine · fine $19,949
Fine
Fine · fine $15,953
Fine
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
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