Cycle 1
Health 2025-02-05 · Fire 2025-02-05
10 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Lincoln, IL
St Clara's Rehab & Senior Care
1-star overall rating with 3-star inspections with 10 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
1450 Castle Manor Drive, Lincoln, IL
(217) 735-1507
Overall
1 / 5
CMS overall stars
Health inspections
3 / 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
99
Certified beds
Average residents
93
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Heritage Operations Group
Operator or chain grouping
Approved since
1992-04-01
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
0.35
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.08
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.18
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.10
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
2.85
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
2.89
CMS adjusted total nurse staffing hours
Case-mix index
1.50
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,632
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.50
Composite VBP score used to determine payment impact.
Payment multiplier
0.9891
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.27
Baseline 18.32% · Performance 18.99% · Measure score 5.27 · Achievement 5.27 · Improvement 0
Healthcare-associated infections
2.50
Baseline 5.41% · Performance 7.09% · Measure score 2.50 · Achievement 2.50 · Improvement 0
Total nurse turnover
6.43
Baseline 79.58% · Performance 41.67% · Measure score 6.43 · Achievement 5.39 · Improvement 6.43
Adjusted total nurse staffing
0
Baseline 3.51 hours · Performance 3.19 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.84% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 76 · Observed rate 6.58% · Lower 95% interval 6.46% |
| Discharge to community | 50.6% |
50.57%
About the same
|
No Different than the National Rate · Eligible stays 47 · Observed rate 48.94% · Lower 95% interval 39.06% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 30.23% |
95.27%
65 pts worse
|
Numerator 13 · Denominator 43 |
| Falls with major injury | 6.98% |
0.77%
6.2 pts worse
|
Numerator 3 · Denominator 43 |
| Discharge self-care score | 26.67% |
53.69%
27 pts worse
|
Numerator 8 · Denominator 30 |
| Discharge mobility score | 23.33% |
50.94%
27.6 pts worse
|
Numerator 7 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 2.33% |
2.29%
About the same
|
Numerator 1 · Denominator 43 · Adjusted rate 2.01% |
| Healthcare-associated infections requiring hospitalization | 7.09% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 49 · Observed rate 6.12% · Lower 95% interval 3.79% |
| Staff COVID-19 vaccination coverage | 9.56% |
8.2%
1.4 pts better
|
Numerator 13 · Denominator 136 |
| Staff flu vaccination coverage | 29.47% |
42%
12.5 pts worse
|
Numerator 56 · Denominator 190 |
| Discharge function score | 30% |
56.45%
26.5 pts worse
|
Numerator 9 · Denominator 30 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 18.52% |
25.2%
6.7 pts worse
|
Numerator 5 · Denominator 27 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
2.0
0.9 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 5.0 |
2.3
2.7 pts worse
|
1.8
3.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 5.0 · Observed 4.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.9% |
89.6%
5.3 pts better
|
93.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 93.0% · Q3 96.3% · Q4 91.7% · 4Q avg 94.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.5% |
91.6%
0.9 pts better
|
95.5%
3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.4% |
3.3%
5.1 pts worse
|
3.3%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 9.3% · Q3 6.2% · Q4 7.1% · 4Q avg 8.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.5% |
50.3%
39.8 pts better
|
11.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 6.8% · Q3 8.6% · Q4 18.7% · 4Q avg 10.5% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
6.5%
2.5 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 4.3% · Q3 6.2% · Q4 4.3% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.8% |
18.5%
0.3 pts worse
|
19.6%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 21.1% · Q3 17.9% · Q4 21.7% · 4Q avg 18.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.2% |
22.8%
5.6 pts better
|
16.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 13.6% · Q3 19.0% · Q4 18.3% · 4Q avg 17.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.3% |
0.1%
0.2 pts worse
|
0.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.2% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents whose ability to walk independently worsened | 37.0% |
17.2%
19.8 pts worse
|
16.3%
20.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.9% · Q2 44.4% · Q3 25.5% · Q4 40.8% · 4Q avg 37.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 32.7% |
15.0%
17.7 pts worse
|
14.9%
17.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.1% · Q2 44.4% · Q3 25.9% · Q4 31.7% · 4Q avg 32.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.0% |
1.1%
2.9 pts worse
|
1.0%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 2.6% · Q3 2.9% · Q4 5.0% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
1.7%
1.1 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.1% |
21.3%
8.8 pts worse
|
19.8%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.9% · Q2 35.9% · Q3 24.5% · Q4 28.5% · 4Q avg 30.1% |
| Percentage of long-stay residents with pressure ulcers | 8.2% |
5.2%
3 pts worse
|
5.1%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 8.5% · Q3 8.6% · Q4 7.2% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.2% |
68.8%
7.4 pts better
|
81.7%
5.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 82.8% · Q2 80.8% · Q3 75.0% · Q4 68.6% · 4Q avg 76.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 37.0% |
14.0%
23 pts worse
|
12.0%
25 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 37.0% · Observed 34.7% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.3%
2.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 49.1% |
63.0%
13.9 pts worse
|
79.7%
30.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 49.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.5% |
26.2%
0.3 pts worse
|
23.9%
2.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.5% · Observed 26.5% · Expected 23.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-03 · Fire 2024-05-03
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2022-11-17 · Fire 2022-11-17
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-02-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-26
F · Potential for more than minimal harm
2025-02-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-02-25
F · Potential for more than minimal harm
2025-02-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-25
E · Potential for more than minimal harm
2025-02-05
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-02-14
E · Potential for more than minimal harm
2025-02-05
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 2025-02-26
D · Potential for more than minimal harm
2025-02-05
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-02-25
F · Potential for more than minimal harm
2024-05-03
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-05-21
F · Potential for more than minimal harm
2024-05-03
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-06-03
F · Potential for more than minimal harm
2024-05-03
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-05-21
F · Potential for more than minimal harm
2024-05-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-29
F · Potential for more than minimal harm
2024-05-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-21
F · Potential for more than minimal harm
2024-05-03
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-05-24
F · Potential for more than minimal harm
2024-05-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-21
E · Potential for more than minimal harm
2024-05-03
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 2024-05-22
E · Potential for more than minimal harm
2024-05-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-18
E · Potential for more than minimal harm
2024-05-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-24
F · Potential for more than minimal harm
2022-11-17
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-01-04
F · Potential for more than minimal harm
2022-11-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-12-30
E · Potential for more than minimal harm
2022-11-17
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 2022-12-09
E · Potential for more than minimal harm
2022-11-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-12-09
Inspection history
Recent health citations
G · Actual harm
2025-10-15
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 2025-10-29
D · Potential for more than minimal harm
2025-08-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-10
D · Potential for more than minimal harm
2025-08-23
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-09-10
G · Actual harm
2025-02-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-23
F · Potential for more than minimal harm
2025-02-05
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 2025-02-23
E · Potential for more than minimal harm
2025-02-05
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 2025-03-24
E · Potential for more than minimal harm
2025-02-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-02-05
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 2025-03-24
D · Potential for more than minimal harm
2025-02-05
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-02-23
D · Potential for more than minimal harm
2025-02-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-23
F · Potential for more than minimal harm
2024-05-03
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 2024-05-21
D · Potential for more than minimal harm
2024-05-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-21
D · Potential for more than minimal harm
2024-05-03
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 2024-05-21
D · Potential for more than minimal harm
2022-11-17
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 2022-12-08
D · Potential for more than minimal harm
2022-11-17
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-11-17
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-11-17
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 2022-12-08
C · Minimal harm
2022-11-17
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-12-08
C · Minimal harm
2022-11-17
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2022-12-08
Penalties and ownership
What sits behind the stars
Ownership
St Claras Senior Services
5% Or Greater Indirect Ownership Interest · Organization
St. Clara's Manor
5% Or Greater Direct Ownership Interest · Organization
Carroll, Dennis
Corporate Director · Individual
Curry, Daniel
Corporate Officer · Individual
Curry, Daniel
Contracted Managing Employee · Individual
Eads, Micheal
W-2 Managing Employee · Individual
Hart, Benjamin
Operational/Managerial Control · Individual
Heritage Operations Group, LLC
Operational/Managerial Control · Organization
Lowney, Cheryl
Operational/Managerial Control · Individual
Reifsteck, Tonita
Corporate Director · Individual
St Claras Senior Services
Operational/Managerial Control · Organization
Underwood, David
Corporate Officer · Individual
Nearby options
Other facilities in reach
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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
H & J Vonderlieth Lvg Ctr, The
Mount Pulaski, IL
4-star overall rating with 5-star inspections with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Mason City Area Nursing Home
Mason City, IL
2-star overall rating with 2-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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