Cycle 1
Health 2024-10-18 · Fire 2024-10-18
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Evanston, IL
Westminster Place
5-star overall rating with 5-star inspections with 4 recent health deficiencies
3200 Grant Street, Evanston, IL
(847) 492-4800
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
105
Certified beds
Average residents
55
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-02-03
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
2.24
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.26
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
3.34
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
5.84
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
2.50
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
5.37
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
1.71
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.19
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
2.28
CMS adjusted RN staffing hours
Adjusted total hours
5.95
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
28%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
321
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
73.25
Composite VBP score used to determine payment impact.
Payment multiplier
1.0238
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.22
Baseline 18.91% · Performance 18.08% · Measure score 7.22 · Achievement 7.22 · Improvement 3.89
Healthcare-associated infections
7.49
Baseline 5.38% · Performance 5.60% · Measure score 7.49 · Achievement 7.49 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
7.27
Baseline 5.10 hours · Performance 5.15 hours · Measure score 7.27 · Achievement 7.27 · Improvement 0.12
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.28% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 416 · Observed rate 6.73% · Lower 95% interval 7.25% |
| Discharge to community | 60.38% |
50.57%
9.8 pts better
|
Better than the National Rate · Eligible stays 399 · Observed rate 57.39% · Lower 95% interval 55.79% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.67% |
95.27%
2.4 pts better
|
Numerator 293 · Denominator 300 |
| Falls with major injury | 0.33% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 300 |
| Discharge self-care score | 53.01% |
53.69%
0.7 pts worse
|
Numerator 88 · Denominator 166 |
| Discharge mobility score | 28.31% |
50.94%
22.6 pts worse
|
Numerator 47 · Denominator 166 |
| Pressure ulcers or injuries, new or worsened | 1.67% |
2.29%
0.6 pts better
|
Numerator 5 · Denominator 300 · Adjusted rate 1.46% |
| Healthcare-associated infections requiring hospitalization | 5.6% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 266 · Observed rate 3.76% · Lower 95% interval 3.43% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 237 |
| Staff flu vaccination coverage | 91.76% |
42%
49.8 pts better
|
Numerator 167 · Denominator 182 |
| Discharge function score | 38.55% |
56.45%
17.9 pts worse
|
Numerator 64 · Denominator 166 |
| Transfer of health information to provider | 99.54% |
95.95%
3.6 pts better
|
Numerator 216 · Denominator 217 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 26 · Denominator 26 |
| Resident COVID-19 vaccinations up to date | 43.14% |
25.2%
17.9 pts better
|
Numerator 66 · Denominator 153 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.0
0.1 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.0 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
2.3
1.9 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
89.6%
8.3 pts better
|
93.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.2% · Q2 94.4% · Q3 100.0% · Q4 100.0% · 4Q avg 97.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
91.6%
8.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.1% |
3.3%
1.2 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 2.8% · Q3 0.0% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.6% |
50.3%
46.7 pts better
|
11.4%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 2.9% · Q3 2.7% · Q4 3.2% · 4Q avg 3.6% |
| Percentage of long-stay residents who lose too much weight | 8.3% |
6.5%
1.8 pts worse
|
5.4%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 11.1% · Q3 6.9% · Q4 0.0% · 4Q avg 8.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.3% |
18.5%
13.2 pts better
|
19.6%
14.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.7% · Q3 6.7% · Q4 6.9% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.0% |
22.8%
10.8 pts better
|
16.7%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 14.3% · Q3 13.6% · 4Q avg 12.0% · 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 | 11.6% |
17.2%
5.6 pts better
|
16.3%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.3% |
15.0%
5.7 pts better
|
14.9%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 3.8% · Q3 6.9% · Q4 11.1% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
1.1%
0.5 pts worse
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.0% · Q3 1.9% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
1.7%
0.4 pts worse
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 0.0% · Q3 2.6% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.2% |
21.3%
7.1 pts better
|
19.8%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.6% · Q2 11.4% · Q3 7.9% · Q4 13.7% · 4Q avg 14.2% |
| Percentage of long-stay residents with pressure ulcers | 10.4% |
5.2%
5.2 pts worse
|
5.1%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 10.5% · Q3 11.2% · Q4 6.3% · 4Q avg 10.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.0% |
68.8%
26.2 pts better
|
81.7%
13.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 87.2% · Q2 96.0% · Q3 98.4% · Q4 99.4% · 4Q avg 95.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.8% |
14.0%
6.2 pts better
|
12.0%
4.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.8% · Observed 7.2% · Expected 10.4% · 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 2.9% · Q2 1.5% · Q3 0.7% · Q4 2.3% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.0% |
63.0%
28 pts better
|
79.7%
11.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.4% |
26.2%
2.8 pts better
|
23.9%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.4% · Observed 21.7% · Expected 22.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-03 · Fire 2023-11-03
2 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-10-27 · Fire 2022-10-27
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-10-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-10-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-10-18
F690 · Quality of Life and Care Deficiencies
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 2024-11-01
D · Potential for more than minimal harm
2024-10-18
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 2024-11-01
D · Potential for more than minimal harm
2023-11-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-13
D · Potential for more than minimal harm
2023-11-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-15
D · Potential for more than minimal harm
2022-10-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-11-15
Penalties and ownership
What sits behind the stars
Ownership
Presbyterian Homes
5% Or Greater Indirect Ownership Interest · Organization
Abi-Antoun, Nadim
Corporate Officer · Individual
Brady, Terri
Corporate Director · Individual
Casper, William
W-2 Managing Employee · Individual
Caughron, Ann
W-2 Managing Employee · Individual
Cirock, Daniel
W-2 Managing Employee · Individual
Clark, Donald
Corporate Director · Individual
Denison, Charles
Corporate Director · Individual
Donnersberger, David
Corporate Director · Individual
Havrilka, Mark
Corporate Officer · Individual
Heenan, Monica
Corporate Director · Individual
Hite, Elinor
Corporate Director · Individual
Hummel, Gregory
Corporate Director · Individual
Kelly, Vincent
Corporate Director · Individual
Kirby, Michael
Corporate Director · Individual
Marx, Dennie
Corporate Director · Individual
Mcafee, Thomas
Corporate Director · Individual
Myers, Gina
W-2 Managing Employee · Individual
Nichols, Elizabeth
Corporate Director · Individual
Noble, Paula
Corporate Director · Individual
Presbyterian Homes Manager LLC
Operational/Managerial Control · Organization
Reese-Clausen, Andrew
W-2 Managing Employee · Individual
Stearns, Neele
Corporate Director · Individual
Swortzel, Todd
Operational/Managerial Control · Individual
Swortzel, Todd
Corporate Officer · Individual
Western, Jane
Corporate Director · Individual
Nearby options
Other facilities in reach
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4-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
#2
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Skokie, IL
4-star overall rating with 4-star inspections with 6 recent health deficiencies
#3
Three Crowns Park
Evanston, IL
3-star overall rating with 2-star inspections with abuse icon flag with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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