Cycle 1
Health 2024-12-12 · Fire 2024-12-12
2 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Winchester, IL
Scott County Nursing Center
4-star overall rating with 5-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Rural Route 2, Winchester, IL
(217) 742-3101
Overall
4 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
49
Certified beds
Average residents
45
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2006-10-16
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
0.60
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.81
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.15
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.56
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.00
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.67
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
0.74
CMS adjusted RN staffing hours
Adjusted total hours
4.40
CMS adjusted total nurse staffing hours
Case-mix index
1.11
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
33%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
529
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
68.16
Composite VBP score used to determine payment impact.
Payment multiplier
1.0214
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
6.23
Baseline 52.63% · Performance 38.23% · Measure score 6.23 · Achievement 6.23 · Improvement 4.68
Adjusted total nurse staffing
7.41
Baseline 4.81 hours · Performance 5.19 hours · Measure score 7.41 · Achievement 7.41 · Improvement 3.37
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | 50% |
95.27%
45.3 pts worse
|
Numerator 12 · Denominator 24 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 24 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 4.17% |
2.29%
1.9 pts worse
|
Numerator 1 · Denominator 24 · Adjusted rate 4.11% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 62 |
| Staff flu vaccination coverage | 36.59% |
42%
5.4 pts worse
|
Numerator 30 · Denominator 82 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · 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 | 1.2 |
2.0
0.8 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.5 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.1 |
2.3
1.8 pts worse
|
1.8
2.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.1 · Observed 4.4 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
89.6%
9.6 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 96.9% · Q4 100.0% · 4Q avg 99.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.1% |
91.6%
5.5 pts better
|
95.5%
1.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.5% |
3.3%
1.8 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.9% |
50.3%
41.4 pts better
|
11.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 10.3% · Q3 10.7% · Q4 0.0% · 4Q avg 8.9% |
| Percentage of long-stay residents who lose too much weight | 5.9% |
6.5%
0.6 pts better
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.7% · Q3 10.3% · Q4 7.7% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.7% |
18.5%
1.8 pts better
|
19.6%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 6.9% · Q3 15.6% · Q4 24.4% · 4Q avg 16.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.0% |
22.8%
16.8 pts better
|
16.7%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.3% · Q3 8.3% · Q4 10.0% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.8% |
0.1%
0.7 pts worse
|
0.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.1% |
17.2%
7.1 pts better
|
16.3%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 12.0% · 4Q avg 10.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.8% |
15.0%
5.2 pts better
|
14.9%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 13.8% · Q3 6.5% · Q4 10.3% · 4Q avg 9.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
1.1%
0.3 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.6% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 7.1% |
1.7%
5.4 pts worse
|
1.7%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.4% · Q3 6.9% · Q4 15.4% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.8% |
21.3%
9.5 pts better
|
19.8%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 6.6% · Q3 15.5% · Q4 17.0% · 4Q avg 11.8% |
| Percentage of long-stay residents with pressure ulcers | 10.9% |
5.2%
5.7 pts worse
|
5.1%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 17.2% · Q3 11.1% · Q4 14.3% · 4Q avg 10.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.3% |
68.8%
26.5 pts better
|
81.7%
13.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.5% · Q2 95.8% · Q3 95.7% · 4Q avg 95.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.0% |
14.0%
5 pts worse
|
12.0%
7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.0% · Observed 16.7% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.6% |
2.3%
3.3 pts worse
|
1.6%
4 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.7% |
63.0%
28.7 pts better
|
79.7%
12 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.5% |
26.2%
0.7 pts better
|
23.9%
1.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.5% · Observed 23.3% · Expected 21.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-25 · Fire 2024-01-25
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2023-02-27 · Fire 2023-02-27
4 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-12-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-24
F · Potential for more than minimal harm
2024-01-25
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-02-28
F · Potential for more than minimal harm
2024-01-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-28
F · Potential for more than minimal harm
2024-01-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-28
F · Potential for more than minimal harm
2023-02-27
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-03-15
F · Potential for more than minimal harm
2023-02-27
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-03-15
Inspection history
Recent health citations
G · Actual harm
2025-09-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-31
E · Potential for more than minimal harm
2024-12-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-15
D · Potential for more than minimal harm
2024-10-10
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-10-31
G · Actual harm
2024-01-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-28
D · Potential for more than minimal harm
2024-01-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-28
F · Potential for more than minimal harm
2023-02-27
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 2023-04-18
F · Potential for more than minimal harm
2023-02-27
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 2023-04-18
F · Potential for more than minimal harm
2023-02-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-18
D · Potential for more than minimal harm
2023-02-27
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 2023-04-18
Penalties and ownership
What sits behind the stars
$0
2025-09-29
Payment Denial
Payment Denial · denial start 2025-10-15 · 16 days
16 day denial
$0
2024-01-25
Payment Denial
Payment Denial · denial start 2024-02-23 · 5 days
5 day denial
Ownership
Ford, Mark
Corporate Officer · Individual
Hays, Lindey
Operational/Managerial Control · Individual
Mahdy, Ahmed
Operational/Managerial Control · Individual
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#3
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