St Clara's Rehab & Senior Care
1450 Castle Manor Drive · Lincoln, IL · 62656 · 2177351507
99 certified beds Non profit - Corporation Chain: Heritage Operations Group
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $70,895 in fines in the last 24 months.
- Inspection results are getting worse cycle over cycle, not better.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
2 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
$70,895 in federal fines in the last 24 months
2 fines — CMS fines are reserved for verified, serious non-compliance.
Total nurse staffing below 3.0 hours per resident-day
2.98 reported hours vs the 3.48 minimum CMS's own staffing study recommends.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 3 of 5 Staffing: 2 of 5 Quality measures: 1 of 5
| Total nurse hours / resident-day | 2.98 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.41 | 0.55–0.75 |
| Weekend hours / resident-day | 2.71 | ≈ weekday level |
| Nursing turnover / year | 36% | median 45% |
| Fines (3-yr window) | 2 · $70,895 |
Inspection citations (19 in the current record)
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Actual harm · G October 15, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected October 29, 2025 · Quality of Life and Care
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Potential for harm · D August 23, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected September 10, 2025 · Quality of Life and Care
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Potential for harm · D August 23, 2025 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected September 10, 2025 · Pharmacy Service
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Actual harm · G February 5, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected February 23, 2025 · Quality of Life and Care
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Potential for harm · D February 5, 2025
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 March 24, 2025 · Quality of Life and Care
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Potential for harm · D February 5, 2025
Provide enough food/fluids to maintain a resident's health.
Corrected February 23, 2025 · Quality of Life and Care
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Potential for harm · D February 5, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Corrected February 23, 2025 · Quality of Life and Care
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Potential for harm · E February 5, 2025
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 March 24, 2025 · Pharmacy Service
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Potential for harm · F February 5, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected February 23, 2025 · Nutrition and Dietary
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Potential for harm · E February 5, 2025
Provide and implement an infection prevention and control program.
Corrected March 24, 2025 · Infection Control
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Potential for harm · F May 3, 2024
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected May 21, 2024 · Resident Rights
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Potential for harm · D May 3, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected May 21, 2024 · Quality of Life and Care
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Potential for harm · D May 3, 2024
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 May 21, 2024 · Pharmacy Service
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Potential for harm · D November 17, 2022
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected December 8, 2022 · Resident Assessment and Care Planning
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Potential for harm · D November 17, 2022
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 December 8, 2022 · Quality of Life and Care
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Potential for harm · D November 17, 2022
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected December 8, 2022 · Quality of Life and Care
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Potential for harm · D November 17, 2022
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 December 8, 2022 · Pharmacy Service
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No harm found · C November 17, 2022
Post nurse staffing information every day.
Corrected December 8, 2022 · Nursing and Physician Services
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No harm found · C November 17, 2022
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected December 8, 2022 · Administration
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| December 17, 2025 | Fine | $56,880 |
| December 17, 2025 | Payment Denial | 14 days |
| October 15, 2025 | Fine | $14,015 |
Better-scoring options nearby
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 145720 · certified since April 1, 1992. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.