Cycle 1
Health 2025-12-11 · Fire 2025-12-11
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Mount Pulaski, IL
H & J Vonderlieth Lvg Ctr, The
4-star overall rating with 5-star inspections with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1120 North Topper Drive, Mount Pulaski, IL
(217) 792-3218
Overall
4 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
57
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Heritage Operations Group
Operator or chain grouping
Approved since
2003-02-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 2 overall / 3 health / 2 staffing / 2 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
0.61
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
2.14
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.31
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.17
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
2.98
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.52
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.61
CMS adjusted RN staffing hours
Adjusted total hours
3.32
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,429
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.67
Composite VBP score used to determine payment impact.
Payment multiplier
0.9832
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.90
Baseline 19.01% · Performance 20.09% · Measure score 2.90 · Achievement 2.90 · Improvement 0
Healthcare-associated infections
0
Baseline 6.00% · Performance 7.79% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.39
Baseline 51.92% · Performance 41.67% · Measure score 5.39 · Achievement 5.39 · Improvement 3.29
Adjusted total nurse staffing
1.18
Baseline 3.38 hours · Performance 3.41 hours · Measure score 1.18 · Achievement 1.18 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.29% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 60 · Observed rate 11.67% · Lower 95% interval 8.42% |
| Discharge to community | 38.87% |
50.57%
11.7 pts worse
|
Worse than the National Rate · Eligible stays 67 · Observed rate 32.84% · Lower 95% interval 29.62% |
| Medicare spending per beneficiary | 1.34 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 39 · Denominator 39 |
| Falls with major injury | 7.69% |
0.77%
6.9 pts worse
|
Numerator 3 · Denominator 39 |
| Discharge self-care score | 34.78% |
53.69%
18.9 pts worse
|
Numerator 8 · Denominator 23 |
| Discharge mobility score | 47.83% |
50.94%
3.1 pts worse
|
Numerator 11 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 10.26% |
2.29%
8 pts worse
|
Numerator 4 · Denominator 39 · Adjusted rate 10.27% |
| Healthcare-associated infections requiring hospitalization | 7.79% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 46 · Observed rate 8.7% · Lower 95% interval 3.87% |
| Staff COVID-19 vaccination coverage | 2.41% |
8.2%
5.8 pts worse
|
Numerator 2 · Denominator 83 |
| Staff flu vaccination coverage | 16.54% |
42%
25.5 pts worse
|
Numerator 21 · Denominator 127 |
| Discharge function score | 47.83% |
56.45%
8.6 pts worse
|
Numerator 11 · Denominator 23 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 14.29% |
25.2%
10.9 pts worse
|
Numerator 3 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.5 |
2.0
1.5 pts better
|
1.9
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
2.3
0.1 pts better
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.8 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.1% |
89.6%
6.5 pts better
|
93.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 94.1% · Q2 93.9% · Q3 96.1% · Q4 100.0% · 4Q avg 96.1% |
| 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 | 14.1% |
3.3%
10.8 pts worse
|
3.3%
10.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 18.4% · Q3 15.7% · Q4 13.0% · 4Q avg 14.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.6% |
50.3%
44.7 pts better
|
11.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 10.4% · Q3 2.0% · Q4 4.0% · 4Q avg 5.6% |
| Percentage of long-stay residents who lose too much weight | 11.2% |
6.5%
4.7 pts worse
|
5.4%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 8.2% · Q3 8.3% · Q4 9.8% · 4Q avg 11.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.5% |
18.5%
2 pts better
|
19.6%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 16.3% · Q3 18.8% · Q4 19.5% · 4Q avg 16.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.0% |
22.8%
1.2 pts worse
|
16.7%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 23.7% · Q3 27.3% · Q4 21.7% · 4Q avg 24.0% · 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 | 35.3% |
17.2%
18.1 pts worse
|
16.3%
19 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.0% · Q2 47.3% · Q3 13.5% · Q4 39.3% · 4Q avg 35.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 31.1% |
15.0%
16.1 pts worse
|
14.9%
16.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.5% · Q2 48.9% · Q3 18.2% · Q4 15.8% · 4Q avg 31.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
1.1%
0.7 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.9% |
1.7%
2.2 pts worse
|
1.7%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 4.1% · Q3 2.0% · Q4 5.6% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.0% |
21.3%
5.7 pts worse
|
19.8%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.4% · Q2 23.4% · Q3 24.2% · Q4 28.7% · 4Q avg 27.0% |
| Percentage of long-stay residents with pressure ulcers | 1.5% |
5.2%
3.7 pts better
|
5.1%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 2.1% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.1% |
68.8%
23.3 pts better
|
81.7%
10.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.9% · Q2 85.4% · Q3 94.4% · Q4 96.7% · 4Q avg 92.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.0% |
14.0%
4 pts worse
|
12.0%
6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.0% · Observed 16.2% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.7% |
2.3%
2.4 pts worse
|
1.6%
3.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 8.7% · Q3 0.0% · Q4 0.0% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
63.0%
37 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.6% |
26.2%
4.6 pts better
|
23.9%
2.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.6% · Observed 16.2% · Expected 17.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-12 · Fire 2024-09-12
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2023-08-03 · Fire 2023-08-03
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-12-11
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2026-01-02
E · Potential for more than minimal harm
2025-12-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2026-01-02
E · Potential for more than minimal harm
2025-12-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2026-01-02
C · Minimal harm
2025-12-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-01-02
F · Potential for more than minimal harm
2024-09-12
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-09-23
E · Potential for more than minimal harm
2024-09-12
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-09-24
F · Potential for more than minimal harm
2023-08-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-11
F · Potential for more than minimal harm
2023-08-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-11
E · Potential for more than minimal harm
2023-08-03
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-08-03
E · Potential for more than minimal harm
2023-08-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-09
E · Potential for more than minimal harm
2023-08-03
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-08-03
E · Potential for more than minimal harm
2023-08-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-08-16
E · Potential for more than minimal harm
2023-08-03
K930 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper storage of liquid oxygen.
Corrected 2023-08-16
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-11
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-12-26
E · Potential for more than minimal harm
2025-12-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-12-11
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 2025-12-26
D · Potential for more than minimal harm
2025-12-11
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-12-26
D · Potential for more than minimal harm
2023-08-03
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 2023-08-18
D · Potential for more than minimal harm
2023-07-02
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-07-20
Penalties and ownership
What sits behind the stars
Ownership
Henry & Jane Vonderlieth Living Center Inc
5% Or Greater Direct Ownership Interest · Organization
Aylesworth, Richard
Corporate Director · Individual
Buenrostro, Kynda
Operational/Managerial Control · Individual
Cross, Thomas
Corporate Director · Individual
Curry, Daniel
Corporate Officer · Individual
Freer, Lynn
Corporate Officer · Individual
Hart, Benjamin
Operational/Managerial Control · Individual
Heritage Operations Group, LLC
Operational/Managerial Control · Organization
Hild, James
Corporate Officer · Individual
Lowney, Cheryl
Operational/Managerial Control · Individual
Martin, Jeff
Corporate Director · Individual
Przykopanski, Pat
Corporate Director · Individual
Wubben, Julian
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Lincoln Village Healthcare
Lincoln, IL
1-star overall rating with 1-star inspections with abuse icon flag with $151,198 in total fines with 31 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
St Clara's Rehab & Senior Care
Lincoln, IL
1-star overall rating with 3-star inspections with 10 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Arc At Hickory Point
Forsyth, IL
2-star overall rating with 2-star inspections with $248,073 in total fines with 17 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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