Cycle 1
Health 2024-12-20 · Fire 2024-12-20
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Batavia, IL
Michaelsen Health Center
5-star overall rating with 4-star inspections with $9,110 in total fines with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
831 North Batavia Avenue, Batavia, IL
(630) 879-4300
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
73
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Covenant Living
Operator or chain grouping
Approved since
1980-11-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 4 overall / 4 health / 4 staffing / 4 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
1.40
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.32
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
3.18
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
4.89
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.71
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
4.58
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
1.11
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
1.43
CMS adjusted RN staffing hours
Adjusted total hours
5.01
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
28%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,879
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.53
Composite VBP score used to determine payment impact.
Payment multiplier
0.9850
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.39
Baseline 19.40% · Performance 20.32% · Measure score 2.39 · Achievement 2.39 · Improvement 0
Healthcare-associated infections
0
Baseline 5.72% · Performance 7.78% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.74
Baseline 52.81% · Performance 44.32% · Measure score 4.74 · Achievement 4.74 · Improvement 2.54
Adjusted total nurse staffing
4.28
Baseline 3.77 hours · Performance 4.30 hours · Measure score 4.28 · Achievement 4.28 · Improvement 2.11
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.26% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 346 · Observed rate 10.69% · Lower 95% interval 8.89% |
| Discharge to community | 56.54% |
50.57%
6 pts better
|
Better than the National Rate · Eligible stays 341 · Observed rate 51.03% · Lower 95% interval 50.84% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.57% |
95.27%
4.3 pts better
|
Numerator 231 · Denominator 232 |
| Falls with major injury | 0.86% |
0.77%
0.1 pts worse
|
Numerator 2 · Denominator 232 |
| Discharge self-care score | 36.69% |
53.69%
17 pts worse
|
Numerator 62 · Denominator 169 |
| Discharge mobility score | 49.11% |
50.94%
1.8 pts worse
|
Numerator 83 · Denominator 169 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 232 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.78% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 212 · Observed rate 7.55% · Lower 95% interval 5.15% |
| Staff COVID-19 vaccination coverage | 0.53% |
8.2%
7.7 pts worse
|
Numerator 1 · Denominator 188 |
| Staff flu vaccination coverage | 42.24% |
42%
0.2 pts better
|
Numerator 68 · Denominator 161 |
| Discharge function score | 44.97% |
56.45%
11.5 pts worse
|
Numerator 76 · Denominator 169 |
| Transfer of health information to provider | 96.88% |
95.95%
0.9 pts better
|
Numerator 62 · Denominator 64 |
| Transfer of health information to patient | 94.87% |
96.28%
1.4 pts worse
|
Numerator 148 · Denominator 156 |
| Resident COVID-19 vaccinations up to date | 21.85% |
25.2%
3.3 pts worse
|
Numerator 26 · Denominator 119 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.0
0.3 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.3 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
2.3
1.2 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
89.6%
7.4 pts better
|
93.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 89.4% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 97.0% |
| 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 | 0.6% |
3.3%
2.7 pts better
|
3.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
50.3%
49.7 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 9.7% |
6.5%
3.2 pts worse
|
5.4%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 8.6% · Q3 6.7% · Q4 16.1% · 4Q avg 9.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.9% |
18.5%
4.6 pts better
|
19.6%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 19.4% · Q3 10.0% · Q4 9.4% · 4Q avg 13.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.8% |
22.8%
6 pts better
|
16.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 16.7% · Q3 17.4% · Q4 20.0% · 4Q avg 16.8% · 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 | 17.7% |
17.2%
0.5 pts worse
|
16.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.4% |
15.0%
1.4 pts worse
|
14.9%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 14.3% · Q3 6.7% · Q4 19.4% · 4Q avg 16.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
1.1%
0.1 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 0.0% · Q4 2.5% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.9% |
1.7%
3.2 pts worse
|
1.7%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.3% · Q3 5.3% · Q4 8.6% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.8% |
21.3%
0.5 pts worse
|
19.8%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.2% · Q2 24.7% · Q3 17.9% · Q4 13.0% · 4Q avg 21.8% |
| 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 1.8% · Q2 1.8% · Q3 3.6% · Q4 3.6% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.0% |
68.8%
26.2 pts better
|
81.7%
13.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.8% · Q2 91.4% · Q3 98.3% · Q4 99.2% · 4Q avg 95.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.5% |
14.0%
2.5 pts worse
|
12.0%
4.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.5% · Observed 13.5% · Expected 9.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
2.3%
0.4 pts better
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.4% · Q3 1.6% · Q4 1.1% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.2% |
63.0%
31.2 pts better
|
79.7%
14.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.5% |
26.2%
3.3 pts worse
|
23.9%
5.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.5% · Observed 25.2% · Expected 20.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-28 · Fire 2023-09-28
9 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2022-12-09 · Fire 2022-12-09
2 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-20
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-01-24
F · Potential for more than minimal harm
2023-09-28
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-10-13
F · Potential for more than minimal harm
2023-09-28
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-10-13
F · Potential for more than minimal harm
2022-12-09
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-01-22
Inspection history
Recent health citations
G · Actual harm
2025-04-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-28
D · Potential for more than minimal harm
2025-04-18
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 2025-04-28
G · Actual harm
2025-04-03
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 2025-04-18
E · Potential for more than minimal harm
2024-12-20
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-01-06
E · Potential for more than minimal harm
2024-12-20
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 2025-01-06
E · Potential for more than minimal harm
2024-12-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-12-20
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-12-20
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 2025-01-06
D · Potential for more than minimal harm
2024-12-20
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-12-20
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-04-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-16
D · Potential for more than minimal harm
2024-04-03
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 2024-04-16
E · Potential for more than minimal harm
2023-09-28
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-10-13
D · Potential for more than minimal harm
2023-09-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-13
D · Potential for more than minimal harm
2023-09-28
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 2023-10-13
D · Potential for more than minimal harm
2023-09-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-13
D · Potential for more than minimal harm
2023-09-28
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 2023-10-13
D · Potential for more than minimal harm
2023-09-28
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2023-10-13
D · Potential for more than minimal harm
2022-12-09
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-12-29
D · Potential for more than minimal harm
2022-12-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-29
Penalties and ownership
What sits behind the stars
$9,110
2025-04-03
Fine
Fine · fine $9,110
Fine
$0
2025-04-03
Payment Denial
Payment Denial · denial start 2025-04-25 · 3 days
3 day denial
Ownership
Covenant Living Communities & Services
5% Or Greater Direct Ownership Interest · Organization
Aagaard, Jon
Corporate Director · Individual
Christensen, Pamela
Corporate Director · Individual
Covenant Living Communities & Services
Operational/Managerial Control · Organization
Cunliffe, Terri
Corporate Officer · Individual
Cunliffe, Terri
W-2 Managing Employee · Individual
Eastburg, Mark
Corporate Director · Individual
Erickson, David
Corporate Officer · Individual
Espinosa, Marc
Corporate Director · Individual
Hodgkinson, Donald
Corporate Director · Individual
Holt, Jody
Corporate Officer · Individual
Manlove, Matt
Corporate Director · Individual
Oxendale, Roger
Corporate Director · Individual
Stante, Marlene
Corporate Director · Individual
Vining, Anne
Corporate Director · Individual
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#3
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