Cycle 1
Health 2024-10-10 · Fire 2024-10-10
5 health deficiencies
Top issue: Resident Rights (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Peoria, IL
Apostolic Christian Skylines
5-star overall rating with 5-star inspections with 5 recent health deficiencies
7023 North East Skyline Drive, Peoria, IL
(309) 691-8091
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
62
Certified beds
Average residents
61
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1997-05-01
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
0.94
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.56
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
3.16
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
4.66
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
4.24
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.57
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.00
CMS adjusted RN staffing hours
Adjusted total hours
4.98
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,764
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
54.12
Composite VBP score used to determine payment impact.
Payment multiplier
1.0089
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.40
Baseline 19.87% · Performance 18.93% · Measure score 5.40 · Achievement 5.40 · Improvement 2.82
Healthcare-associated infections
3.55
Baseline 6.30% · Performance 6.77% · Measure score 3.55 · Achievement 3.55 · Improvement 0
Total nurse turnover
5.52
Baseline 39.24% · Performance 41.11% · Measure score 5.52 · Achievement 5.52 · Improvement 0
Adjusted total nurse staffing
7.17
Baseline 4.85 hours · Performance 5.12 hours · Measure score 7.17 · Achievement 7.17 · Improvement 2.41
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.57% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 92 · Observed rate 4.35% · Lower 95% interval 6.19% |
| Discharge to community | 51.29% |
50.57%
0.7 pts better
|
No Different than the National Rate · Eligible stays 79 · Observed rate 50.63% · Lower 95% interval 41.56% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 84.85% |
95.27%
10.4 pts worse
|
Numerator 28 · Denominator 33 |
| Falls with major injury | 3.03% |
0.77%
2.3 pts worse
|
Numerator 1 · Denominator 33 |
| Discharge self-care score | 51.61% |
53.69%
2.1 pts worse
|
Numerator 16 · Denominator 31 |
| Discharge mobility score | 32.26% |
50.94%
18.7 pts worse
|
Numerator 10 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 33 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.77% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 47 · Observed rate 4.26% · Lower 95% interval 3.71% |
| Staff COVID-19 vaccination coverage | 13.04% |
8.2%
4.8 pts better
|
Numerator 24 · Denominator 184 |
| Staff flu vaccination coverage | 91.88% |
42%
49.9 pts better
|
Numerator 181 · Denominator 197 |
| Discharge function score | 41.94% |
56.45%
14.5 pts worse
|
Numerator 13 · Denominator 31 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
2.0
1 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.7 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
2.3
1.3 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
89.6%
8.6 pts better
|
93.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.3% · Q2 96.2% · Q3 100.0% · Q4 100.0% · 4Q avg 98.2% |
| 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 | 3.2% |
3.3%
0.1 pts better
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 1.9% · Q3 1.8% · Q4 5.2% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.9% |
50.3%
48.4 pts better
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 2.0% · Q3 0.0% · Q4 1.8% · 4Q avg 1.9% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
6.5%
6.5 pts better
|
5.4%
5.4 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 who received an antianxiety or hypnotic medication | 19.5% |
18.5%
1 pts worse
|
19.6%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 25.6% · Q3 20.4% · Q4 17.6% · 4Q avg 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.0% |
22.8%
6.8 pts better
|
16.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 17.5% · Q3 16.3% · Q4 17.0% · 4Q avg 16.0% · 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 | 14.5% |
17.2%
2.7 pts better
|
16.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 12.8% · 4Q avg 14.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.7% |
15.0%
2.7 pts worse
|
14.9%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 21.1% · Q3 15.9% · Q4 21.7% · 4Q avg 17.7% · 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 | 5.6% |
1.7%
3.9 pts worse
|
1.7%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 5.9% · Q3 3.6% · Q4 8.8% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.3% |
21.3%
6 pts better
|
19.8%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 22.2% · Q3 10.9% · Q4 9.2% · 4Q avg 15.3% |
| 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 6.6% · Q2 2.0% · Q3 3.8% · Q4 4.2% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.2% |
68.8%
27.4 pts better
|
81.7%
14.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.3% · Q2 93.5% · Q3 100.0% · Q4 100.0% · 4Q avg 96.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.2% |
14.0%
2.2 pts worse
|
12.0%
4.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.2% · Observed 13.8% · Expected 9.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.4% |
2.3%
2.1 pts worse
|
1.6%
2.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 4.8% · Q3 5.0% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.9% |
63.0%
33.9 pts better
|
79.7%
17.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 4.5% |
26.2%
21.7 pts better
|
23.9%
19.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.5% · Observed 3.4% · Expected 18.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-20 · Fire 2023-07-20
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-10-06 · Fire 2022-10-06
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-12
F559 · Resident Rights Deficiencies
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 2025-04-25
E · Potential for more than minimal harm
2024-10-10
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-10-10
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-10-10
F625 · Resident Rights Deficiencies
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 2024-11-01
D · Potential for more than minimal harm
2024-10-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-01
G · Actual harm
2023-12-21
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 2024-01-12
D · Potential for more than minimal harm
2023-07-20
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-08-12
D · Potential for more than minimal harm
2022-10-06
F688 · Quality of Life and Care Deficiencies
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 2022-10-31
D · Potential for more than minimal harm
2022-10-06
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-10-31
Penalties and ownership
What sits behind the stars
Ownership
Apostolic Christian Church Of Peoria
5% Or Greater Direct Ownership Interest · Organization
Aeschleman, Steve
Operational/Managerial Control · Individual
Berchtold, David
Corporate Director · Individual
Brown, Jennifer
Operational/Managerial Control · Individual
Calame, Jeremy
Corporate Officer · Individual
Carlson, James
Corporate Director · Individual
Draves, Julie
Operational/Managerial Control · Individual
Feucht, Matthew
Corporate Director · Individual
Gorenz And Associates, Ltd
Operational/Managerial Control · Organization
Graham, Bruce
Corporate Officer · Individual
Hodel, Benj
Corporate Director · Individual
Knobloch, Paul
Corporate Director · Individual
Lindahl, Larry
Operational/Managerial Control · Individual
Morton Community Bank
Operational/Managerial Control · Organization
Pineda, Michelle
Operational/Managerial Control · Individual
Professional Therapy Services Inc
Operational/Managerial Control · Organization
Randel, Hannah
Operational/Managerial Control · Individual
Robert Rein Cpa
Operational/Managerial Control · Organization
Schick, Stanley
Corporate Officer · Individual
Smith, Yevett
Operational/Managerial Control · Individual
Steffen, Joanne
Corporate Director · Individual
Thomas, Dean
Operational/Managerial Control · Individual
Waibel, Michael
Corporate Director · Individual
Wettstein, Crystal
Corporate Director · Individual
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#3
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