Presence Saints Mary and Elizabeth Medical Center
An acute care hospital in Chicago, Illinois 60622
2233 W Division St, Chicago, Illinois 60622. (312) 770-2000.
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The short answer
Record last released by CMS on Oct 20, 2026.
- 3of 5 CMS’s overall rating
- 3of 5 patient survey rating
- 2 deficiencies cited in the last three years
- 493 beds
Each figure’s source sits beside it, in its section below.
What these words mean3
- Star ratings
- CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
The last inspection on record was on Feb 19, 2026: a complaint inspection.
2 deficiencies cited in the last three years.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
2 deficiencies in 1 month of the last 36. Last cited May 2025. Most serious: Standard-level. The last 3 years, to Nov 5, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Dec | |||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
May 1, 2025: complaint inspection2 deficiencies
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Care Of Patients
The inspectors’ words, 429 words
“CARE OF PATIENTS CFR(s): 482.12(c) In accordance with hospital policy, the governing body must ensure that the following requirements are met: This Standard is not met as evidenced by: 39802 Based on document review and interview, it was determined that for 2 of 3 rapid responses reviewed of pediatric behavioral health patients (Pt. #11), the hospital failed to ensure that critical care staff responded as required by policy. Findings include: 1. The hospital’s Medical Staff Bylaws (revised November 20, 2024), was reviewed and required, “...Responsibilities of Medical Staff... comply with applicable provisions of ...Hospital policies...” 2. The hospital’s policy titled, “Rapid Response Team” (revised 03/01/2025), was reviewed and required, “ ...To provide urgent medical assistance and intervention for acute medical problems in the non-critical care patient areas ... The RRT [Rapid Response Team] is composed of the following staff who have expertise in critical care management and principles of resuscitation and can facilitate movement of patients to a higher level of care when needed. 1... 2. Critical Care Resident and/or Critical Care Intensivist ...” 3. The clinical record of Pt. #11 was reviewed on 05/01/2025. Pt. #11 was admitted on 03/01/2025 to the 11th floor Adolescent/Pediatric Behavioral Health Unit, with a diagnosis of aggressive behavior. The record indicated that two rapid responses were called on 03/13/2025, one at 4:39 PM and again at 7:48 PM, both for acute change in condition/seizure-like activity. The record indicated that the rapid response team included a Family Medicine Resident (MD#10); however, lacked documentation that staff from critical care (such as a resident or intensivist) attended/responded to the rapid response. 4. An interview was conducted with ICU (Intensive Care Unit) Nurse Manager (E#12) on 05/01/2025, at approximately 11:00 AM. E#12 stated that when a rapid response is called on the 11th floor (Peds BHU), the expectation is that an ED (emergency department nurse) and ED doctor will go to that unit. E#12 stated that the ICU Charge Nurse and the ICU Resident and/or Intensivist will also respond to the rapid as well. 5. An interview was conducted with Family Resident (MD#10) on 05/01/2025, at approximately 2:00 PM. MD#10 stated that Family Medicine Residents are on-call to respond to all rapid responses throughout the hospital. MD#10 stated that generally on the adult units, ICU will respond to the all rapids; however, for the rapid responses that occurred on the Pediatric Unit on 03/13/2025, MD#10 stated that no resident or attending from ICU responded. MD#10 stated that MD#10 does have PALS (pediatric advanced life support) certification but does not have critical care expertise with pediatric patients.”
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Patient Rights: Informed Consent
The inspectors’ words, 533 words
“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 40079 Based on document review and interview it was determined that for 2 of 3 (Pt.#6 and Pt.#7) clinical records reviewed for informed consent, the hospital failed to obtain consent for treatment and psychotropic medication from the patient to make informed decisions of patient’s care. Findings include: 1. On 04/30/2025, the hospital’s policy titled, “Administration of Psychotropic Medication” (revised 10/20/2023) was reviewed and required, “... G. Psychotropic Medication - means medication whose use or antipsychotic, antidepressant, anti-manic, anti-anxiety ...or behavioral management purposes ... III. Required Procedures... 1. Behavioral health patients are provided services pursuant to an individualized treatment plan formulated with the patients... or other person designated by the patient. 2. The physician or designee must advice adult patients... or Guardian... of the right to refuse services including psychotropic medications ... a physician or designee shall advice the patient, in writing of the side effects, risks and benefits of the treatment ... After the written information is provided, it must be noted in the patient’s medical record ...” 2. On 04/30/2025, the clinical record of Pt. #6 was reviewed. Pt.#6 was admitted on 04/28/2025, to the hospital’s adult medical/psychiatric unit with a diagnosis of aggressive behavior. On 04/30/2025 at 8:52 AM, Zoloft (anti-depressant medication) 100 mg (milligram) tablet was given as a scheduled dose and Brexpiprazole (anti-psychotic medication) 1 mg tablet as a scheduled dose to Pt. #6. The “Department of Psychiatry Medication Consent” form was not completed for Pt. #6 to indicate that the information was provided to Pt.#6 about the medications to make an informed decision. 3. On 04/30/2025, the clinical record of Pt. #7 was reviewed. Pt.#7 was admitted on 04/13/2025 to the adult medical/psychiatric unit with a diagnosis of psychosis (mental disorder) and discharged on 04/28/2025. Pt.#7 received PRN (as needed) haloperidol (anti-psychotic) 5 mg injection on 04/16/2025, 04/17/2025, 04/20/2025, and 04/22/2025. Lorazepam (anti-anxiety medication)1 mg injection PRN on 04/16/2025, 04/17/2025, and 04/22/2025, and risperidone (anti-psychotic medication) 2 mg tablets as a scheduled twice a day on 04/24/2025 through 04/28/2025. The “Department of Psychiatry Medication Consent” form was not completed for Pt. #7 to indicate that the information was provided to Pt.#7 about the medications to make an informed decision. 4. An interview was conducted on 04/30/2025 at approximately 12:20 PM, with Registered Nurse (RN/E#8). E#8 stated that for all patients receiving psychotropic medications, the patient will be informed of reason for medication, desired effects, and side effects. The patients have the right to refuse their medications, which will be documented, and the physician will be notified. The medication consent form is required to be complete and signed by the physician to indicate that the patient was provided education about their medications.”
All 5 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Feb 19, 2026 | Complaint inspection | No deficiencies cited |
| Jul 10, 2025 | Complaint inspection | No deficiencies cited |
| May 1, 2025 | Complaint inspection | 2 deficiencies cited |
| Feb 23, 2024 | Complaint inspection | No deficiencies cited |
| Jan 3, 2024 | Complaint inspection | No deficiencies cited |
How do patients fare?
- CMS’s overall CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System. for it is 3 of 5.
- Of the measures behind its CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System., CMS counts against the national value: mortality, 0 better and 0 worse of 6; safety of care, 1 better and 0 worse of 4; readmission, 0 better and 0 worse of 8.
- Patients rate it 3 of 5 in CMS’s patient survey (1,045 surveys completed, Oct 1, 2024 to Sep 30, 2025): 65% rated it 9 or 10 out of 10, and 69% would definitely recommend it.
- Infections, compared by CMS with the national benchmark (Oct 1, 2024 to Sep 30, 2025): surgical site infections after colon surgery, no different than national benchmark; MRSA bloodstream infections, better than the national benchmark; C. diff infections, better than the national benchmark.
- CMS’s patient safety composite for serious complications, PSI 90, Jul 1, 2022 to Jun 30, 2024: no different than the national value.
- Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): heart attack 11.4%, heart failure 10%, pneumonia 13.4%, COPD 7.9%, stroke 10.8%. CMS gives no comparison with the national rate for them in this release.
- Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): heart attack 14.6%, heart failure 21.5%, pneumonia 17.9%, COPD 19.5%. CMS gives no comparison with the national rate for them in this release.
- After outpatient care, compared by CMS: unplanned hospital visits after a colonoscopy, no different than the national rate; hospital admissions after outpatient chemotherapy, no different than the national rate; emergency visits after outpatient chemotherapy, no different than the national rate.
- Emergency department patients spent a median of 192 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025).
- 47% of patients with severe sepsis or septic shock got the care CMS measures, SEP-1 (Oct 1, 2024 to Sep 30, 2025).
- Medicare’s spending per patient here is 1.03 times the national median (Jan 1, 2024 to Dec 31, 2024).
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | 3 of 5 |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | 3 of 5 |
Is it certified, and in good standing?
- Medicare-certified acute care hospital since Jul 1, 1966.
- Ownership: voluntary non-profit - church.
- It is accredited by The Joint Commission, whose surveys stand in for the state’s routine inspections.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency on record in the last three years.
- It has an inpatient rehabilitation unit of 15 beds, which CMS lists apart as a rehabilitation facility.
- Voluntary non-profit - Church.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Has it been penalized?
- CMS doesn’t publish fines or other penalties for hospitals.
- Not among the hospitals whose Medicare payments CMS cut under the Hospital-Acquired Condition Reduction Program for fiscal year 2026.
- 2 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
What do patients say about their care?
- CMS doesn’t publish staffing levels for hospitals.
- In CMS’s patient survey, patients rate how well its nurses communicated 3 of 5.
- 70% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- Prime Healthcare Services, Inc. owns 100% directly since Mar 20, 2024.
- 5 owners or officers are people: Steven Aleman (corporate officer); Steven Aleman (corporate director); Steven Aleman (managing employee (on the payroll)); Christopher Doan (corporate officer); Christopher Doan (managing employee (on the payroll)).
- CMS’s Provider of Services file records 3 changes of ownership, the latest on Mar 1, 2025.
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
| Organisation | Role | Share | Since |
|---|---|---|---|
| Prime Healthcare Services, Inc. | Owns 5% or more directly | 100% | Mar 20, 2024 |
| Prime Healthcare Holdings Inc. | Owns 5% or more through other companies | 100% | Mar 20, 2024 |
How does it compare nearby?
- Of the 56 hospitals CMS lists in Cook County, 40 have an overall star rating from CMS: 5 rated 5 of 5, 8 rated 4 of 5, 10 rated 3 of 5, 9 rated 2 of 5, 8 rated 1 of 5.
- CMS rates this one 3 of 5.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
- QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
- CMS doesn’t publish staffing levels for hospitals.
- In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.
Sources
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Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated yearly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q3_2026.csv).
Released Oct 14, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Nov 5, 2026.
From the hospital
The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.