Cycle 1
Health 2024-10-10 · Fire 2024-10-10
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Alton, IL
Alton Memorial Rehab & Therapy
3-star overall rating with 3-star inspections with $15,360 in total fines with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1251 College Avenue, Alton, IL
(618) 463-7330
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
64
Certified beds
Average residents
44
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Bjc Healthcare
Operator or chain grouping
Approved since
1967-01-24
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
3 facilities
Chain averages 4 overall / 4 health / 4 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
0.93
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.20
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.50
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
4.64
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
2.13
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
4.15
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.61
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.84
CMS adjusted RN staffing hours
Adjusted total hours
4.17
CMS adjusted total nurse staffing hours
Case-mix index
1.52
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,273
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.12
Composite VBP score used to determine payment impact.
Payment multiplier
0.9983
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.58
Baseline 23.48% · Performance 22.14% · Measure score 1.58 · Achievement 0 · Improvement 1.58
Healthcare-associated infections
6.08
Baseline 7.02% · Performance 6.02% · Measure score 6.08 · Achievement 6.08 · Improvement 4.44
Total nurse turnover
7.27
Baseline 38.30% · Performance 33.96% · Measure score 7.27 · Achievement 7.27 · Improvement 2.72
Adjusted total nurse staffing
3.12
Baseline 3.62 hours · Performance 3.96 hours · Measure score 3.12 · Achievement 3.12 · Improvement 1.10
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.99% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 294 · Observed rate 14.63% · Lower 95% interval 9.3% |
| Discharge to community | 62.3% |
50.57%
11.7 pts better
|
Better than the National Rate · Eligible stays 286 · Observed rate 53.85% · Lower 95% interval 56.06% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 92.66% |
95.27%
2.6 pts worse
|
Numerator 164 · Denominator 177 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 177 |
| Discharge self-care score | 62.31% |
53.69%
8.6 pts better
|
Numerator 81 · Denominator 130 |
| Discharge mobility score | 45.38% |
50.94%
5.6 pts worse
|
Numerator 59 · Denominator 130 |
| Pressure ulcers or injuries, new or worsened | 0.56% |
2.29%
1.7 pts better
|
Numerator 1 · Denominator 177 · Adjusted rate 0.64% |
| Healthcare-associated infections requiring hospitalization | 6.02% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 168 · Observed rate 5.36% · Lower 95% interval 4.16% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 71 |
| Staff flu vaccination coverage | 35.53% |
42%
6.5 pts worse
|
Numerator 27 · Denominator 76 |
| Discharge function score | 53.08% |
56.45%
3.4 pts worse
|
Numerator 69 · Denominator 130 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 53 · Denominator 53 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 111 · Denominator 111 |
| Resident COVID-19 vaccinations up to date | 28.16% |
25.2%
3 pts better
|
Numerator 29 · Denominator 103 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.6%
10.4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 13.8% |
3.3%
10.5 pts worse
|
3.3%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.3% |
50.3%
47 pts better
|
11.4%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.3% |
| Percentage of long-stay residents who lose too much weight | 1.7% |
6.5%
4.8 pts better
|
5.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 38.7% |
18.5%
20.2 pts worse
|
19.6%
19.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 38.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.2% |
22.8%
7.6 pts better
|
16.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.2% · 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 · 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 | 28.3% |
15.0%
13.3 pts worse
|
14.9%
13.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 28.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.1%
1.1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
1.7%
0.1 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.1% |
21.3%
1.8 pts worse
|
19.8%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.1% |
| Percentage of long-stay residents with pressure ulcers | 13.0% |
5.2%
7.8 pts worse
|
5.1%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 80.4% |
68.8%
11.6 pts better
|
81.7%
1.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 52.2% · Q2 84.0% · Q3 95.7% · Q4 89.5% · 4Q avg 80.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.9% |
14.0%
4.9 pts worse
|
12.0%
6.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.9% · Observed 16.0% · Expected 9.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
2.3%
1.8 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.5% · Q3 0.5% · Q4 0.5% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.9% |
63.0%
19.9 pts better
|
79.7%
3.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.2% |
26.2%
7 pts worse
|
23.9%
9.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.2% · Observed 28.2% · Expected 20.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-30 · Fire 2023-11-30
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2022-12-01 · Fire 2022-12-01
11 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-10-10
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-11-22
F · Potential for more than minimal harm
2023-11-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-08
E · Potential for more than minimal harm
2022-12-01
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-12-20
Inspection history
Recent health citations
G · Actual harm
2026-01-06
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 2026-01-12
D · Potential for more than minimal harm
2026-01-06
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 2026-01-12
D · Potential for more than minimal harm
2025-01-10
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2025-01-21
D · Potential for more than minimal harm
2025-01-08
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-01-09
D · Potential for more than minimal harm
2025-01-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-01-09
G · Actual harm
2024-10-10
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 2024-10-24
G · Actual harm
2024-10-10
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-10-24
F · Potential for more than minimal harm
2024-10-10
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 2024-10-24
D · Potential for more than minimal harm
2024-10-10
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 2024-10-24
D · Potential for more than minimal harm
2024-10-10
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-10-10
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-10-24
G · Actual harm
2024-05-10
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 2024-05-14
F · Potential for more than minimal harm
2024-02-06
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 2024-03-01
F · Potential for more than minimal harm
2023-11-30
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 2023-12-15
E · Potential for more than minimal harm
2023-11-30
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-11-30
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-11-30
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 2023-12-15
E · Potential for more than minimal harm
2023-11-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-11-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-04-04
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-17
D · Potential for more than minimal harm
2023-04-04
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 2023-04-17
D · Potential for more than minimal harm
2023-04-04
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-04-17
D · Potential for more than minimal harm
2023-04-04
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 2023-04-17
G · Actual harm
2022-12-01
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 2022-12-23
F · Potential for more than minimal harm
2022-12-01
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 2022-12-23
F · Potential for more than minimal harm
2022-12-01
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-12-23
F · Potential for more than minimal harm
2022-12-01
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2022-12-23
E · Potential for more than minimal harm
2022-12-01
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 2022-12-23
E · Potential for more than minimal harm
2022-12-01
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 2022-12-23
Penalties and ownership
What sits behind the stars
$15,360
2024-10-10
Fine
Fine · fine $15,360
Fine
Ownership
Alton Memorial Hospital
Operational/Managerial Control · Organization
Ayres, Gary
Operational/Managerial Control · Individual
Ayres, Gary
Corporate Director · Individual
Bethesda Health Group Inc
Operational/Managerial Control · Organization
Bjc Health System
Operational/Managerial Control · Organization
Braasch, David
Corporate Director · Individual
Braasch, David
Corporate Officer · Individual
Byrne, Roger
Operational/Managerial Control · Individual
Byrne, Roger
Corporate Director · Individual
Childers, Timothy
Corporate Director · Individual
Christian Health Services Development Corporation
Operational/Managerial Control · Organization
Dianati, Behfar
Operational/Managerial Control · Individual
Erker, Melissa
Corporate Director · Individual
Goins, Sheila
Corporate Director · Individual
Harms, Craig
Corporate Director · Individual
Huddleston, Ebony
Corporate Director · Individual
Koesterer, Susan
Corporate Director · Individual
Koesterer, Susan
Corporate Officer · Individual
Liszewski, Kathryn
Operational/Managerial Control · Individual
Loy, Kenneth
Corporate Director · Individual
Magruder, Joan
Corporate Director · Individual
Patton, Tanya
Corporate Director · Individual
Ryrie, Edward
Corporate Director · Individual
Tchoukaleff, Michael
Corporate Director · Individual
Thompson, Stephen
Corporate Director · Individual
Trzaska, Kenneth
Corporate Director · Individual
Turner, Geoffrey
Corporate Director · Individual
Turpin, Debra
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
La Bella Of Alton
Alton, IL
1-star overall rating with 2-star inspections with $125,544 in total fines with 15 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Nexus at Alton
Alton, IL
1-star overall rating with 1-star inspections with abuse icon flag with $507,317 in total fines with 35 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Bria Of Woodriver
Wood River, IL
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $133,325 in total fines with 18 recent health deficiencies
Jump out