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St. Martha Manor

St. Martha Manor, 4621 North Racine Avenue, Chicago, IL 60640

St. Martha Manor, located on Chicago’s North Side has an overall average rating. The facility has 132 certified beds that allow Medicaid recipients to become residents. The ownership, a corporation, is for profit. The last standard inspection was done on November 12, 2015. St. Martha Manor fell short by failing to inform the physician promptly of a significant change in one of three residents in a sample interview.

In this instance it was reported that a resident was seen and heard groaning and moaning seated in a chair at the side of his bed. The resident was tearing up stating that “I can’t breathe and I can’t get into my bed.” An individual staff member was seen walking away and when asked why she didn’t assist the resident, she stated she is not a nurse but would call one. Just three minutes later a nurse did approach the resident and determined that the oxygen tank at bedside was empty. The nurse left and returned with another oxygen tank, but that too was found to be empty. It took a total of 25 minutes before a full oxygen tank was brought in. More than thirty minutes after the resident was first seen moaning and groaning the blood oxygenation saturation had dipped to just 89%. The staff did not notify the resident’s physician and no follow up evaluation was recorded. The given reason for not notifying the physician was that the nursing staff was waiting for a full oxygen tank. It has been the policy of St. Martha Manor to notify a resident’s physician in a case of a change in a resident’s condition or status.

In this observation it was shown that the facility failed to identify that a restraint was in use and failed to follow restraint policy for one of three residents. In another observation one resident had both side rails of the bed raised. The resident was unable to lower either rail. The assistant director of nursing at St. Martha Manor said that the rails were raised to prevent falls. However there was no document of a physician order that this resident be constrained this way. The facility was found to have failed to ensure that bed mattress for two residents were adequate. Here the mattresses were worn, thin and in disrepair. The St. Martha Manor policy on mattresses is that staff is to report any deficiency in the bedding of a resident. The mattresses were extremely thin and should have been replaced.

The staffing category for St. Martha Manor was rated below average. The total number of licensed nurse staff hours per resident per day was just 56 minutes compared to one hour and 34 minutes for the Illinois average and one hour and 41 minutes which is the national average. Breaking out the registered nursing hours per resident per day was just 24 minutes whereas the state average was 57 minutes and the U.S. average was 51 minutes.

St. Martha Manor fell short when it came to the percent of short-stay residents assessed and given, appropriately the season flu vaccine at just 30.8% of the time. This percentage was a lot lower than the Illinois and U.S. averages. This facility was also found to be deficient compared to the state and national averages when it came to giving the appropriate pneumococcal vaccine to short-stay residents. St. Martha Manor was shown to deliver this vaccine just 18.9% of the times where Illinois nursing homes on average would deliver the vaccine 78.6% of the time.

There were no fines assessed to St. Martha Manor in the last 3 years.

1 Vital Statistics
Number of Beds: 132 certified bedsinformation

Beds in the nursing home that have been approved by the federal government to participate in Medicare or Medicaid.

Accepts: Medicaidinformation

Shows if the nursing home participates in the Medicare, Medicaid, or both.

2 Key Ratings
Star Rating Summary
Overall Rating information

Medicare assigns the overall star rating based on a nursing homes's performance on 3 separate measures: Health inspections, staffing, and quality measures. Each of these domains have their own star ratings, with more stars meaning better quality of care

Three Stars Average
Health Inspection information

Medicare assigns the star rating based on a nursing home’s weighted score from recent health inspections. More stars means fewer health risks

Three Stars Average
Staffing information

Medicare assigns the star rating based on the nursing home’s staffing hours for Registered Nurses (RNs), Licensed Practice Nurses (LPNs), Licensed Vocational Nurses (LVNs), and Nurse aides. More stars means a better level of staffing per nursing home resident

Two Stars Below Average
RN Staffing Two Stars Below Average
Quality Measures information

Medicare assigns the star rating based on data from a select set of clinical data measures. More stars means better quality of care

Three Stars Average
3 Key Short Stay Statistics
Description Mado Healthcare - Uptown Illinois
Average
Percent of short-stay residents who self-report moderate to severe pain
Lower percentages are better.
2.6% 10.2%
Percentage of SNF residents with pressure ulcers that are new or worsened
Lower percentages are better.
Not Available% Not Available
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
Higher percentages are better.
50.0% 72.8%
Percent of short-stay residents assessed and given, appropriately, the pneumococcal vaccine
Higher percentages are better.
32.2% 74.7%
Percentage of short-stay residents who got antipsychotic medication for the first time
Lower percentages are better.
Not Available% 2.1%
4 Key Long Stay Statistics
Description Mado Healthcare - Uptown Illinois
Average
Percent of long-stay residents experiencing one or more falls with major injury
Lower percentages are better.
2.7% 3.3%
Percent of long-stay residents with a urinary tract infection
Lower percentages are better.
0.8% 3.1%
Percent of long-stay residents who self-report moderate to severe pain
Lower percentages are better.
1.4% 4.9%
Percent of long-stay high-risk residents with pressure ulcers
Lower percentages are better.
5.1% 7.6%
Percent of long-stay low-risk residents who lose control of their bowels or bladder
Lower percentages are better.
24.7% 46.1%
Percent of long-stay residents who have or had a catheter inserted and left in their bladder
Lower percentages are better.
1.4% 2.4%
Percent of long-stay residents who were physically restrained
Lower percentages are better.
0.0% 0.3%
Percentage of long-stay residents whose ability to move independently worsened
Lower percentages are better.
17.7% 16.5%
Percent of long-stay residents whose need for help with daily activities has increased
Lower percentages are better.
21.0% 13.8%
Percent of long-stay residents who lose too much weight
Lower percentages are better.
4.4% 6.3%
Percent of long-stay residents who have depressive symptoms
Lower percentages are better.
20.1% 19.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication
Lower percentages are better.
8.0% 20.2%
Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine
Higher percentages are better.
96.8% 92.9%
Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine
Higher percentages are better.
67.7% 89.7%
Percent of long-stay residents who received an antipsychotic medication
Lower percentages are better.
87.3% 18.8%
5 Inspection Summary

Date of standard health inspection: 01/04/2019
Total number of health deficiencies: 6
Average number of health deficiencies in Illinois: 10.6

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