Beardstown, IL

Beardstown Health & Rehab Ctr

4-star overall rating with 5-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

8306 St Lukes Drive, Beardstown, IL

(217) 323-4055

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

5 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

79

Certified beds

Average residents

66

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Summit Healthcare Consulting

Operator or chain grouping

Approved since

1997-11-25

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

9 facilities

Chain averages 3 overall / 4 health / 1 staffing / 3 quality stars

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

0.27

Registered nurse staffing · state 0.73 · national 0.68

LPN hours / resident day

0.95

Licensed practical nurse staffing · state 0.64 · national 0.87

Aide hours / resident day

2.19

Nurse aide staffing · state 2.13 · national 2.35

Total nurse hours

3.41

All reported nurse hours · state 3.49 · national 3.89

Licensed hours

1.22

RN + LPN hours · state 1.36 · national 1.54

Weekend hours

3.10

Weekend nurse staffing · state 3.09 · national 3.43

Weekend RN hours

0.18

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

0.24

CMS adjusted RN staffing hours

Adjusted total hours

3.06

CMS adjusted total nurse staffing hours

Case-mix index

1.52

Higher values indicate more complex resident acuity

RN turnover

57%

Annual RN turnover · state 44% · national 45%

Total nurse turnover

41%

Annual nurse turnover · state 46% · national 46%

SNF VBP

Value-based purchasing

Program rank

3,646

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

43.30

Composite VBP score used to determine payment impact.

Payment multiplier

0.9963

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

6.37

Baseline 18.29% · Performance 18.48% · Measure score 6.37 · Achievement 6.37 · Improvement 0

Healthcare-associated infections

4.81

Baseline 5.58% · Performance 6.40% · Measure score 4.81 · Achievement 4.81 · Improvement 0

Total nurse turnover

6.14

Baseline 43.40% · Performance 38.57% · Measure score 6.14 · Achievement 6.14 · Improvement 2.10

Adjusted total nurse staffing

0

Baseline 3.64 hours · Performance 3.12 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.38%	10.72% 0.3 pts better	No Different than the National Rate · Eligible stays 54 · Observed rate 7.41% · Lower 95% interval 6.41%
Discharge to community	48.86%	50.57% 1.7 pts worse	No Different than the National Rate · Eligible stays 50 · Observed rate 48% · Lower 95% interval 37.11%
Medicare spending per beneficiary	1.17	1.02 0.1 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 30 · Denominator 30
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 30
Discharge self-care score	33.33%	53.69% 20.4 pts worse	Numerator 9 · Denominator 27
Discharge mobility score	22.22%	50.94% 28.7 pts worse	Numerator 6 · Denominator 27
Pressure ulcers or injuries, new or worsened	3.33%	2.29% 1 pts worse	Numerator 1 · Denominator 30 · Adjusted rate 4.06%
Healthcare-associated infections requiring hospitalization	6.4%	7.12% 0.7 pts better	No Different than the National Rate · Eligible stays 40 · Observed rate 2.5% · Lower 95% interval 3.13%
Staff COVID-19 vaccination coverage	9.9%	8.2% 1.7 pts better	Numerator 10 · Denominator 101
Staff flu vaccination coverage	Not Available	42%	Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Discharge function score	37.04%	56.45% 19.4 pts worse	Numerator 10 · Denominator 27
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 17 · 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	1.1	2.0 0.9 pts better	1.9 0.8 pts better	Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.0 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	3.7	2.3 1.4 pts worse	1.8 1.9 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.7 · Observed 3.4 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	89.6% 10.4 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.5%	91.6% 6.9 pts better	95.5% 3 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.5%
Percentage of long-stay residents experiencing one or more falls with major injury	2.8%	3.3% 0.5 pts better	3.3% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.5% · Q3 3.1% · Q4 4.9% · 4Q avg 2.8% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	80.5%	50.3% 30.2 pts worse	11.4% 69.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 83.6% · Q2 76.3% · Q3 71.0% · Q4 92.7% · 4Q avg 80.5%
Percentage of long-stay residents who lose too much weight	11.6%	6.5% 5.1 pts worse	5.4% 6.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 7.9% · Q3 17.7% · Q4 13.3% · 4Q avg 11.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	21.7%	18.5% 3.2 pts worse	19.6% 2.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 21.9% · Q3 21.0% · Q4 23.0% · 4Q avg 21.7%
Percentage of long-stay residents who received an antipsychotic medication	28.0%	22.8% 5.2 pts worse	16.7% 11.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 29.8% · Q2 17.8% · Q3 31.1% · Q4 32.7% · 4Q avg 28.0% · 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	11.3%	17.2% 5.9 pts better	16.3% 5 pts better	Long Stay · 2024Q4-2025Q3 · Q2 13.6% · 4Q avg 11.3% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	14.0%	15.0% 1 pts better	14.9% 0.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 18.0% · Q3 8.2% · Q4 6.8% · 4Q avg 14.0% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.0%	1.1% 0.1 pts better	1.0% About the same	Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.3% · Q3 0.0% · Q4 1.2% · 4Q avg 1.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.4%	1.7% 1.3 pts better	1.7% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	23.4%	21.3% 2.1 pts worse	19.8% 3.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 21.0% · Q2 25.2% · Q3 24.4% · Q4 22.8% · 4Q avg 23.4%
Percentage of long-stay residents with pressure ulcers	7.2%	5.2% 2 pts worse	5.1% 2.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.6% · Q3 11.3% · Q4 10.1% · 4Q avg 7.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	99.4%	68.8% 30.6 pts better	81.7% 17.7 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.6% · Q3 100.0% · Q4 100.0% · 4Q avg 99.4%
Percentage of short-stay residents who had an outpatient emergency department visit	6.1%	14.0% 7.9 pts better	12.0% 5.9 pts better	Short Stay · 20240701-20250630 · Adjusted 6.1% · Observed 6.1% · Expected 11.2% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	4.0%	2.3% 1.7 pts worse	1.6% 2.4 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 4.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	88.1%	63.0% 25.1 pts better	79.7% 8.4 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 88.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	8.5%	26.2% 17.7 pts better	23.9% 15.4 pts better	Short Stay · 20240701-20250630 · Adjusted 8.5% · Observed 9.1% · Expected 25.4% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-05-08 · Fire 2024-05-08

4 health deficiencies

Top issue: Infection Control (2 deficiencies)

5 fire-safety deficiencies

Top issue: Emergency Preparedness (2 deficiencies)

Cycle 2 Health 2023-05-18 · Fire 2023-05-18

2 health deficiencies

Top issue: Pharmacy Service (1 deficiency)

5 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 3 Health 2022-03-03 · Fire 2022-03-03

8 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-05-08

E37 · Emergency Preparedness Deficiencies

Fire Safety

Establish staff and initial training requirements.

Corrected 2024-06-03

F · Potential for more than minimal harm 2024-05-08

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2024-06-07

F · Potential for more than minimal harm 2024-05-08

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-06-07

F · Potential for more than minimal harm 2024-05-08

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-06-03

F · Potential for more than minimal harm 2024-05-08

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-07-19

F · Potential for more than minimal harm 2023-05-18

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-06-23

F · Potential for more than minimal harm 2023-05-18

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-06-23

E · Potential for more than minimal harm 2023-05-18

K222 · Egress Deficiencies

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 2023-06-23

E · Potential for more than minimal harm 2023-05-18

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2023-06-23

E · Potential for more than minimal harm 2023-05-18

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2023-06-23

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-08-05

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-08-06

E · Potential for more than minimal harm 2024-05-08

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 2024-06-03

D · Potential for more than minimal harm 2024-05-08

F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Corrected 2024-06-03

D · Potential for more than minimal harm 2024-05-08

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-06-03

G · Actual harm 2023-05-18

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2023-05-31

D · Potential for more than minimal harm 2023-05-18

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 2023-05-31

F · Potential for more than minimal harm 2022-03-03

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2022-03-22

E · Potential for more than minimal harm 2022-03-03

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2022-03-22