See every facility — official ratings, family reviews, no referral fees.
Nursing HomeMedicaid Investigative

St Clara's Rehab & Senior Care

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

1450 Castle Manor Drive, Lincoln, IL 6265699 bedsLicensed & Active
2/5
Medicare
Inspection
Quality
Staffing
Google rating
3.8/5

based on 19 Google reviews

5
4
3
2
1
St Clara's Rehab & Senior Care Nursing Home in Lincoln, IL — Street View
Street View

Watch St Clara's Rehab & Senior Care

Get an email when new inspections, ratings, or penalties are published for this facility.

We’ll only email you about this — no spam, unsubscribe anytime.

3/ 10
moderate Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (1/5 stars)
  • Low staffing rating (1/5 stars)

Bottom 25% in IL · Critically understaffed (RN) · Worst in HERITAGE OPERATIONS GROUP chain · No penalties on record

Source: Medicare data

What this means for your family

While the facility is physically beautiful and clean, the recurring reports of medication errors and staffing issues are significant red flags. We strongly recommend that you conduct unannounced visits during weekends or evenings to observe actual staff responsiveness and ask for a detailed explanation of their medication administration protocols.

Google Reviews

Google Reviews

19 reviews on Google
St. Clara's Rehab & Senior Care presents a stark contrast in experiences, with some families praising the facility's cleanliness and friendly atmosphere, while others report severe concerns regarding medication management and staffing. Critics highlight a lack of personal connection and responsiveness, while supporters describe the environment as beautiful and well-managed. Prospective families should be aware of significant allegations regarding neglect and unprofessional communication.

Quality Themes

Tap a score for details
FoodN/AStaff5.0Clean9.0ActivitiesN/AMeds1.0MemoryN/AComms3.0ValueN/A

Strengths

  • Clean, well-maintained facility
  • Beautiful indoor and outdoor common areas
  • Friendly and attentive staff (noted by some reviewers)

Concerns

  • Chronic understaffing and slow response to call lights (mentioned by 2 reviewers)
  • Poor medication management and over-sedation (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

234'17(2)'19(1)'21(1)'23(3)'25(3)

Distribution · 21 analyzed

5
13
4
0
3
0
2
1
1
7

How They Respond to Reviews

5%response rate

This facility rarely responds to reviews.

Questions for Your Tour

  • 1With the current staffing levels, what specific protocols do you have in place to ensure call lights are answered promptly and residents' needs are met in a timely manner?
  • 2Can you walk me through your current medication management process and how you ensure accuracy and safety for residents who require complex daily regimens?
  • 3I noticed the facility has beautiful common areas; how do you encourage residents to socialize and participate in daily activities to ensure they stay engaged and active?
  • 4Given the recent focus on improving communication, what is your standard process for keeping family members updated on changes in their loved one's health or care plan?
  • 5How does your team coordinate with outside physicians and specialists to ensure that medical care is consistent and that any concerns regarding over-medication are proactively addressed?
  • 6What steps is the leadership team taking to address the recent CMS staffing ratings and ensure that every resident receives the consistent, personalized attention they deserve?

Personalized based on this facility's data


Key Review Excerpts

The staff was kind from what I saw but but I absolutely hate the way they treated my loved one. Do not send your loved ones here! They over-medicated my loved one and they couldn’t even stay awake long enough for visits.

Loved one's family member · 2023★★☆☆☆

Witnessed MANY breaks they took being on their cell phones at the desk while call lights would continually ring. I caught them in numerous lies and in process or reporting them.

Visitor · 2022☆☆☆☆

Very attentive and friendly staff. Facility is kept nice and clean. Beautiful terrace and indoor sitting areas are available for visiting.

Visitor · 2023★★★★★
Source: 19 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.41hrs
54%
Registered nurses for medical care
Total Nursing
2.98hrs
73%
All nurses + aides combined
Staff Turnover
36%
Lower is better (< 30% = good)
RN Turnover
43%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
1/ 5
Better Than Avg

4

measures

Worse Than Avg

8

measures

Mixed Results

5

measures

Long-Stay Residents
😔

Residents with depression symptoms

↓ Lower is better
This Facility11.8%
Better than Avg
Here
11.8%
US
12.1%
IL
52.5%
Logan
15.3%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

🚶

Residents whose walking got worse

↓ Lower is better
This Facility32.5%
Worse than Avg
Here
32.5%
US
15.3%
IL
15.9%
Logan
14.4%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility28.3%
Worse than Avg
Here
28.3%
US
14.4%
IL
14.2%
Logan
13.4%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility29.6%
Worse than Avg
Here
29.6%
US
19.4%
IL
21.1%
Logan
18.0%
💉

Residents vaccinated for the flu

↑ Higher is better
This Facility92.5%
Mixed vs Avgs
Here
92.5%
US
95.5%
IL
91.8%
Logan
99.3%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility16.0%
Mixed vs Avgs
Here
16.0%
US
15.5%
IL
21.8%
Logan
16.7%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility49.1%
Worse than Avg
Here
49.1%
US
79.8%
IL
63.1%
Logan
87.4%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility74.1%
Mixed vs Avgs
Here
74.1%
US
81.8%
IL
69.0%
Logan
88.3%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
1.6%
IL
2.4%
Logan
2.0%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

10deficiencies
3penalties
Near state avg (12.0)
3 complaint-triggered

Families have filed complaints that triggered inspections revealing significant issues with medication safety and care quality that persist across multiple years. The facility shows recurring problems in three main areas: fire safety and building maintenance, medication management, and wound care. While all deficiencies show correction dates, the pattern of repeated violations in fire safety systems, medication errors, and pressure ulcer care across surveys from 2022 to 2025 suggests ongoing challenges maintaining consistent standards.

Oct 15, 2025Complaint
1
0689Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Aug 23, 2025Complaint
2
0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0760Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Feb 5, 2025Routine
14
0686Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0345Potential for harm · WidespreadCorrected

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

0353Potential for harm · WidespreadCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0712Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

0918Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0758Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

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.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0271Potential for harm · PatternCorrected

Egress Deficiencies

Have exits that are accessible at all times.

0321Potential for harm · PatternCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0690Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

0692Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

0355Potential for harm · IsolatedCorrected

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

May 3, 2024Routine
13
0623Potential for harm · WidespreadCorrected

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

0037Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Establish staff and initial training requirements.

0039Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

0291Potential for harm · WidespreadCorrected

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

0353Potential for harm · WidespreadCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0712Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

0914Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

0918Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0321Potential for harm · PatternCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0324Potential for harm · PatternCorrected

Smoke Deficiencies

Provide properly protected cooking facilities.

0920Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

0686Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

0758Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

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.

Nov 17, 2022Routine
10
0039Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

0712Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

0321Potential for harm · PatternCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0363Potential for harm · PatternCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0688Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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.

0744Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

0758Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

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.

0732Minimal · WidespreadCorrected

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

0847Minimal · WidespreadCorrected

Administration Deficiencies

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Federal Penalties

Fine

Dec 17, 2025

$56,880

Payment Denial

Dec 17, 2025

14-day denial

Fine

Oct 15, 2025

$14,015

Ownership & Operations

Who Operates This Facility

Owner / Operator

St Clara's Rehab & Senior Care

Organization Type

nonprofit

Chain Affiliation

Chain Name

Heritage Operations Group

Chain Size

9 facilities nationwide

Chain avg rating: 2.1/5 · Rank 7 of 8 (Worst)

Ownership & Management

Owners

St. Clara's Manor

Owner · Organization

100%

Key personnel

Anderson, KearyOfficer / DirectorBurbage, EllenOfficer / DirectorCarroll, DennisOfficer / DirectorDehner, ConnieOfficer / DirectorKasa, PaulOfficer / Director
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 2 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

Call