Geneseo, IL

Hammond-Henry District Hsp

4-star overall rating with 2-star inspections with abuse icon flag with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

600 North College Avenue, Geneseo, IL

(309) 944-6431

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

38

Certified beds

Average residents

37

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1982-10-14

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

0.98

Registered nurse staffing · state 0.73 · national 0.68

LPN hours / resident day

0.26

Licensed practical nurse staffing · state 0.64 · national 0.87

Aide hours / resident day

2.79

Nurse aide staffing · state 2.13 · national 2.35

Total nurse hours

4.02

All reported nurse hours · state 3.49 · national 3.89

Licensed hours

1.24

RN + LPN hours · state 1.36 · national 1.54

Weekend hours

3.52

Weekend nurse staffing · state 3.09 · national 3.43

Weekend RN hours

0.63

Weekend registered nurse coverage · state 0.56 · national 0.47

Physical therapist

0.01

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

1.14

CMS adjusted RN staffing hours

Adjusted total hours

4.67

CMS adjusted total nurse staffing hours

Case-mix index

1.18

Higher values indicate more complex resident acuity

RN turnover

44%

Annual RN turnover · state 44% · national 45%

Total nurse turnover

33%

Annual nurse turnover · state 46% · national 46%

SNF VBP

Value-based purchasing

Program rank

1,143

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

Performance score

59.47

Composite VBP score used to determine payment impact.

Payment multiplier

1.0147

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

7.19

Baseline 35.48% · Performance 34.29% · Measure score 7.19 · Achievement 7.19 · Improvement 0.63

Adjusted total nurse staffing

4.70

Baseline 3.78 hours · Performance 4.42 hours · Measure score 4.70 · Achievement 4.70 · Improvement 2.69

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.73%	10.72% 1 pts better	No Different than the National Rate · Eligible stays 27 · Observed rate 0% · Lower 95% interval 5.42%
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	0.62	1.02 0.4 pts better
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 9 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	2.53%	8.2% 5.7 pts worse	Numerator 2 · Denominator 79
Staff flu vaccination coverage	82.57%	42% 40.6 pts better	Numerator 90 · Denominator 109
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
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 3 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 2 · 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	0.3	2.0 1.7 pts better	1.9 1.6 pts better	Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.2 · 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 0.7 · Expected 1.3 · 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	94.1%	91.6% 2.5 pts better	95.5% 1.4 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 94.1%
Percentage of long-stay residents experiencing one or more falls with major injury	3.7%	3.3% 0.4 pts worse	3.3% 0.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 5.9% · Q4 5.7% · 4Q avg 3.7% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	2.2%	50.3% 48.1 pts better	11.4% 9.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 3.0% · Q4 2.9% · 4Q avg 2.2%
Percentage of long-stay residents who lose too much weight	1.6%	6.5% 4.9 pts better	5.4% 3.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	11.2%	18.5% 7.3 pts better	19.6% 8.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 9.7% · Q3 9.7% · Q4 9.1% · 4Q avg 11.2%
Percentage of long-stay residents who received an antipsychotic medication	4.4%	22.8% 18.4 pts better	16.7% 12.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 3.6% · Q3 3.3% · Q4 6.2% · 4Q avg 4.4% · 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	30.9%	17.2% 13.7 pts worse	16.3% 14.6 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 30.9% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	18.2%	15.0% 3.2 pts worse	14.9% 3.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 33.3% · Q3 13.3% · Q4 18.8% · 4Q avg 18.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.9%	1.1% 0.2 pts better	1.0% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.5%	1.7% 0.2 pts better	1.7% 0.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	24.1%	21.3% 2.8 pts worse	19.8% 4.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 35.2% · Q3 27.9% · Q4 18.0% · 4Q avg 24.1%
Percentage of long-stay residents with pressure ulcers	2.6%	5.2% 2.6 pts better	5.1% 2.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 6.9% · Q4 3.2% · 4Q avg 2.6% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	68.8% 31.2 pts better	81.7% 18.3 pts better	Short Stay · 2024Q4-2025Q3 · 4Q avg 100.0%

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-09-27 · Fire 2024-09-27

4 health deficiencies

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

2 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Cycle 2 Health 2023-08-24 · Fire 2023-08-24

4 health deficiencies

Top issue: Infection Control (1 deficiency)

1 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Cycle 3 Health 2022-10-14 · Fire 2022-10-14

0 health deficiencies

No concentrated health issue counts in this cycle.

4 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-09-27

E15 · Emergency Preparedness Deficiencies

Fire Safety

Address subsistence needs for staff and patients.

Corrected 2024-10-16

E · Potential for more than minimal harm 2024-09-27

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2024-10-16

F · Potential for more than minimal harm 2023-08-24

E26 · Emergency Preparedness Deficiencies

Fire Safety

Establish roles under a Waiver declared by secretary.

Corrected 2023-09-14

F · Potential for more than minimal harm 2022-10-14

K346 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Corrected 2022-10-31

F · Potential for more than minimal harm 2022-10-14

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2022-10-27

F · Potential for more than minimal harm 2022-10-14

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2022-10-28

F · Potential for more than minimal harm 2022-10-14

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2022-10-28

Inspection history

Recent health citations

J · Immediate jeopardy 2025-10-09

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-11-13

J · Immediate jeopardy 2025-10-09

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-11-13

D · Potential for more than minimal harm 2025-10-09

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2025-11-13

F · Potential for more than minimal harm 2025-01-03

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-02-17

D · Potential for more than minimal harm 2024-09-27

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-11-11

D · Potential for more than minimal harm 2023-08-24

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-09-08

D · Potential for more than minimal harm 2023-08-24

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2023-09-08

C · Minimal harm 2023-08-24

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 2023-09-08

Penalties and ownership