Cycle 1
Health 2025-03-28 · Fire 2025-03-28
12 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Carlinville, IL
Lakeside Health & Rehab Center
1-star overall rating with 2-star inspections with $58,500 in total fines with 12 recent health deficiencies
1200 University Avenue, Carlinville, IL
(217) 854-4433
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
95
Certified beds
Average residents
54
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Summit Healthcare Consulting
Operator or chain grouping
Approved since
1982-12-01
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
0.38
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.07
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.54
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.99
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.45
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.45
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.30
CMS adjusted RN staffing hours
Adjusted total hours
3.11
CMS adjusted total nurse staffing hours
Case-mix index
1.76
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,567
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.92
Composite VBP score used to determine payment impact.
Payment multiplier
0.9823
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.87
Baseline 19.11% · Performance 18.71% · Measure score 5.87 · Achievement 5.87 · Improvement 1.40
Healthcare-associated infections
0
Baseline 7.15% · Performance 8.79% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.10
Baseline 65.52% · Performance 55.10% · Measure score 2.10 · Achievement 2.10 · Improvement 2.06
Adjusted total nurse staffing
0
Baseline 3.12 hours · Performance 2.68 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.35% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 54 · Observed rate 9.26% · Lower 95% interval 6.5% |
| Discharge to community | 47.84% |
50.57%
2.7 pts worse
|
No Different than the National Rate · Eligible stays 30 · Observed rate 40% · Lower 95% interval 35.55% |
| Medicare spending per beneficiary | 1.13 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 48 · Denominator 48 |
| Falls with major injury | 4.17% |
0.77%
3.4 pts worse
|
Numerator 2 · Denominator 48 |
| Discharge self-care score | 20% |
53.69%
33.7 pts worse
|
Numerator 6 · Denominator 30 |
| Discharge mobility score | 23.33% |
50.94%
27.6 pts worse
|
Numerator 7 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 14.58% |
2.29%
12.3 pts worse
|
Numerator 7 · Denominator 48 · Adjusted rate 11.84% |
| Healthcare-associated infections requiring hospitalization | 8.79% |
7.12%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 35 · Observed rate 17.14% · Lower 95% interval 5.19% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 76 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 76 |
| Discharge function score | 20% |
56.45%
36.5 pts worse
|
Numerator 6 · Denominator 30 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · 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 | 3.7% |
25.2%
21.5 pts worse
|
Numerator 1 · Denominator 27 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.0
0.3 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.7 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 5.3 |
2.3
3 pts worse
|
1.8
3.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 5.3 · Observed 5.5 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.5% |
89.6%
1.1 pts worse
|
93.4%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 93.0% · Q2 85.2% · Q3 77.4% · Q4 98.1% · 4Q avg 88.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.7% |
91.6%
2.9 pts worse
|
95.5%
6.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 11.1% |
3.3%
7.8 pts worse
|
3.3%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 9.3% · Q3 13.2% · Q4 9.4% · 4Q avg 11.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 43.2% |
50.3%
7.1 pts better
|
11.4%
31.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 8.9% · Q3 58.7% · Q4 85.1% · 4Q avg 43.2% |
| Percentage of long-stay residents who lose too much weight | 14.7% |
6.5%
8.2 pts worse
|
5.4%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.1% · Q2 18.6% · Q3 7.5% · Q4 0.0% · 4Q avg 14.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.7% |
18.5%
9.2 pts worse
|
19.6%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 29.8% · Q3 32.6% · Q4 26.2% · 4Q avg 27.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.8% |
22.8%
About the same
|
16.7%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 24.3% · Q3 25.0% · Q4 21.9% · 4Q avg 22.8% · 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 | 25.4% |
17.2%
8.2 pts worse
|
16.3%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.2% |
15.0%
2.2 pts worse
|
14.9%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 16.3% · Q3 22.5% · Q4 5.4% · 4Q avg 17.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.3% |
1.1%
1.2 pts worse
|
1.0%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.8% · Q3 0.0% · Q4 5.3% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
1.7%
0.7 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.3% |
21.3%
13 pts worse
|
19.8%
14.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.1% · Q2 39.5% · Q3 29.2% · Q4 35.8% · 4Q avg 34.3% |
| Percentage of long-stay residents with pressure ulcers | 8.3% |
5.2%
3.1 pts worse
|
5.1%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 10.9% · Q3 10.3% · Q4 6.1% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 33.7% |
68.8%
35.1 pts worse
|
81.7%
48 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 42.2% · Q2 30.2% · Q3 24.5% · Q4 39.5% · 4Q avg 33.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.0% |
14.0%
About the same
|
12.0%
2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.0% · Observed 14.6% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.0% |
2.3%
0.7 pts worse
|
1.6%
1.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 4.5% · Q3 4.0% · Q4 0.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 28.3% |
63.0%
34.7 pts worse
|
79.7%
51.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 28.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.3% |
26.2%
8.9 pts better
|
23.9%
6.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.3% · Observed 18.8% · Expected 25.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-18 · Fire 2024-04-18
14 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-04-14 · Fire 2023-04-14
5 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
2025-11-13
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 2025-12-04
J · Immediate jeopardy
2025-09-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-11-06
E · Potential for more than minimal harm
2025-06-11
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-06-18
G · Actual harm
2025-03-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-17
G · Actual harm
2025-03-28
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 2025-04-17
F · Potential for more than minimal harm
2025-03-28
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-04-17
F · Potential for more than minimal harm
2025-03-28
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 2025-04-17
D · Potential for more than minimal harm
2025-03-28
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2025-04-17
D · Potential for more than minimal harm
2025-03-28
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 2025-04-17
D · Potential for more than minimal harm
2025-03-28
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-04-17
D · Potential for more than minimal harm
2025-03-28
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-04-17
D · Potential for more than minimal harm
2025-03-07
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-03-25
G · Actual harm
2025-01-30
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 2025-02-12
D · Potential for more than minimal harm
2025-01-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-12
E · Potential for more than minimal harm
2025-01-09
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-01-17
F · Potential for more than minimal harm
2025-01-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-21
D · Potential for more than minimal harm
2025-01-06
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 2025-01-17
G · Actual harm
2024-09-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-09
F · Potential for more than minimal harm
2024-04-18
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-05-01
F · Potential for more than minimal harm
2024-04-18
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-04-18
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 2024-05-01
D · Potential for more than minimal harm
2024-04-18
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 2024-05-01
D · Potential for more than minimal harm
2024-04-18
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 2024-05-01
D · Potential for more than minimal harm
2024-04-18
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 2024-05-01
D · Potential for more than minimal harm
2024-04-18
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-04-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-01
D · Potential for more than minimal harm
2023-12-19
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-12-19
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 2024-01-05
G · Actual harm
2023-04-14
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-05-05
E · Potential for more than minimal harm
2023-04-14
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 2023-05-05
C · Minimal harm
2023-04-14
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2023-05-05
Penalties and ownership
What sits behind the stars
$27,583
2025-03-07
Fine
Fine · fine $27,583
Fine
$10,793
2025-01-30
Fine
Fine · fine $10,793
Fine
$20,124
2023-04-14
Fine
Fine · fine $20,124
Fine
Ownership
Sc Illinois Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Albers, Chas
W-2 Managing Employee · Individual
Apogee Tr
5% Or Greater Indirect Ownership Interest · Organization
Lichtman, Shalom
Operational/Managerial Control · Individual
Lichtman, Shalom
Corporate Officer · Individual
Light Man LLC
Operational/Managerial Control · Organization
Sc Illinois I Tbd Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
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