Cycle 1
Health 2024-09-06 · Fire 2024-09-06
28 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (6 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Charleston, IL
Charleston Rehab and Nursing
2-star overall rating with 2-star inspections with 28 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
716 Eighteenth Street, Charleston, IL
(217) 345-7054
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
139
Certified beds
Average residents
57
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Tutera Senior Living & Health Care
Operator or chain grouping
Approved since
1989-06-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
25 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 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
0.74
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.49
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.20
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.43
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.23
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
2.90
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.45
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
0.68
CMS adjusted RN staffing hours
Adjusted total hours
3.15
CMS adjusted total nurse staffing hours
Case-mix index
1.49
Higher values indicate more complex resident acuity
RN turnover
64%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,644
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.64
Composite VBP score used to determine payment impact.
Payment multiplier
0.9822
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.44
Baseline 21.40% · Performance 20.76% · Measure score 1.44 · Achievement 1.44 · Improvement 0.95
Healthcare-associated infections
4.11
Baseline 6.78% · Performance 6.61% · Measure score 4.11 · Achievement 4.11 · Improvement 0.48
Total nurse turnover
0.56
Baseline 45.24% · Performance 61.40% · Measure score 0.56 · Achievement 0.56 · Improvement 0
Adjusted total nurse staffing
1.75
Baseline 2.99 hours · Performance 3.58 hours · Measure score 1.75 · Achievement 1.75 · Improvement 1.58
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.22% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 74 · Observed rate 8.11% · Lower 95% interval 6.8% |
| Discharge to community | 37.46% |
50.57%
13.1 pts worse
|
Worse than the National Rate · Eligible stays 48 · Observed rate 31.25% · Lower 95% interval 28.5% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 40 · Denominator 40 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 40 |
| Discharge self-care score | 15.38% |
53.69%
38.3 pts worse
|
Numerator 4 · Denominator 26 |
| Discharge mobility score | 19.23% |
50.94%
31.7 pts worse
|
Numerator 5 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 40 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.61% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 35 · Observed rate 2.86% · Lower 95% interval 3.49% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 23.08% |
56.45%
33.4 pts worse
|
Numerator 6 · Denominator 26 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · 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 | 50% |
25.2%
24.8 pts better
|
Numerator 12 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 5.1 |
2.0
3.1 pts worse
|
1.9
3.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 5.1 · Observed 4.3 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.9 |
2.3
1.6 pts worse
|
1.8
2.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.9 · Observed 3.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 60.2% |
89.6%
29.4 pts worse
|
93.4%
33.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 60.7% · Q2 62.0% · Q3 53.1% · Q4 65.2% · 4Q avg 60.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.7% |
91.6%
5.1 pts better
|
95.5%
1.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.0% |
3.3%
2.7 pts worse
|
3.3%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 8.0% · Q3 4.1% · Q4 2.2% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 13.7% |
50.3%
36.6 pts better
|
11.4%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 19.0% · Q3 10.9% · Q4 7.1% · 4Q avg 13.7% |
| Percentage of long-stay residents who lose too much weight | 5.0% |
6.5%
1.5 pts better
|
5.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.3% · Q3 9.5% · Q4 7.3% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.5% |
18.5%
6 pts worse
|
19.6%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 24.5% · Q3 22.2% · Q4 26.2% · 4Q avg 24.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.1% |
22.8%
1.3 pts worse
|
16.7%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 25.0% · Q3 25.0% · Q4 24.2% · 4Q avg 24.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 1.0% |
0.1%
0.9 pts worse
|
0.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.3% |
17.2%
1.9 pts better
|
16.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 7.6% · Q3 17.9% · Q4 16.4% · 4Q avg 15.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.9% |
15.0%
1.9 pts worse
|
14.9%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 13.3% · Q3 22.5% · Q4 13.2% · 4Q avg 16.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
1.1%
0.6 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.7%
1.2 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.2% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.2% |
21.3%
6.1 pts better
|
19.8%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.5% · Q2 16.2% · Q3 21.2% · Q4 6.9% · 4Q avg 15.2% |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
5.2%
2.3 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 2.7% · Q3 2.4% · Q4 2.4% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 30.9% |
68.8%
37.9 pts worse
|
81.7%
50.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 41.9% · Q3 29.4% · Q4 26.1% · 4Q avg 30.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.4% |
14.0%
2.6 pts better
|
12.0%
0.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.4% · Observed 10.5% · Expected 10.3% · 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 · 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 | 56.2% |
63.0%
6.8 pts worse
|
79.7%
23.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 56.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.3% |
26.2%
1.9 pts better
|
23.9%
0.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.3% · Observed 23.7% · Expected 23.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-21 · Fire 2023-11-21
21 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-11-18 · Fire 2022-11-18
13 health deficiencies
Top issue: Resident Rights (5 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-06
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-10-04
F · Potential for more than minimal harm
2024-09-06
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-10-04
F · Potential for more than minimal harm
2024-09-06
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-10-15
F · Potential for more than minimal harm
2024-09-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-07
F · Potential for more than minimal harm
2024-09-06
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2024-10-04
E · Potential for more than minimal harm
2024-09-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-17
E · Potential for more than minimal harm
2024-09-06
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-10-07
E · Potential for more than minimal harm
2024-09-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-02
F · Potential for more than minimal harm
2023-11-21
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-01-12
F · Potential for more than minimal harm
2023-11-21
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-01-12
F · Potential for more than minimal harm
2023-11-21
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-01-12
F · Potential for more than minimal harm
2023-11-21
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-01-12
F · Potential for more than minimal harm
2023-11-21
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-01-12
F · Potential for more than minimal harm
2023-11-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-19
F · Potential for more than minimal harm
2023-11-21
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-01-12
F · Potential for more than minimal harm
2023-11-21
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-01-12
E · Potential for more than minimal harm
2023-11-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-01-19
F · Potential for more than minimal harm
2022-11-18
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2022-12-15
F · Potential for more than minimal harm
2022-11-18
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2022-12-15
F · Potential for more than minimal harm
2022-11-18
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-12-15
E · Potential for more than minimal harm
2022-11-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-15
E · Potential for more than minimal harm
2022-11-18
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-12-15
Inspection history
Recent health citations
G · Actual harm
2025-09-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-26
D · Potential for more than minimal harm
2025-09-02
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 2025-09-26
D · Potential for more than minimal harm
2025-09-02
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-09-26
D · Potential for more than minimal harm
2025-09-02
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 2025-09-26
D · Potential for more than minimal harm
2025-09-02
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 2025-09-26
D · Potential for more than minimal harm
2025-09-02
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-09-26
D · Potential for more than minimal harm
2025-09-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-11-15
D · Potential for more than minimal harm
2025-09-02
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-09-26
F · Potential for more than minimal harm
2025-04-09
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-04-09
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-04-09
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-05-02
D · Potential for more than minimal harm
2024-11-12
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-11-13
F · Potential for more than minimal harm
2024-09-06
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-10-01
F · Potential for more than minimal harm
2024-09-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-09
F · Potential for more than minimal harm
2024-09-06
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-10-03
F · Potential for more than minimal harm
2024-09-06
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2024-10-09
E · Potential for more than minimal harm
2024-09-06
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-10-01
E · Potential for more than minimal harm
2024-09-06
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 2024-10-09
E · Potential for more than minimal harm
2024-09-06
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-09-06
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-09-06
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-09-06
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-09-06
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 2024-10-01
D · Potential for more than minimal harm
2024-09-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-09-06
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 2024-10-01
D · Potential for more than minimal harm
2024-09-06
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 2024-10-09
D · Potential for more than minimal harm
2024-09-06
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-06
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-06
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-10-09
E · Potential for more than minimal harm
2024-06-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-30
D · Potential for more than minimal harm
2024-06-28
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 2024-07-30
D · Potential for more than minimal harm
2024-02-29
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-03-21
D · Potential for more than minimal harm
2024-02-29
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 2024-03-21
D · Potential for more than minimal harm
2024-02-29
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-03-21
D · Potential for more than minimal harm
2024-02-29
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 2024-03-21
F · Potential for more than minimal harm
2023-11-21
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 2023-12-15
E · Potential for more than minimal harm
2023-11-21
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
2023-11-21
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 2023-12-15
D · Potential for more than minimal harm
2023-11-21
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 2023-12-15
D · Potential for more than minimal harm
2023-11-21
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-21
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-21
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-21
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-21
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 2023-12-15
D · Potential for more than minimal harm
2023-11-21
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-21
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 2023-12-15
D · Potential for more than minimal harm
2023-11-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-21
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-21
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 2023-12-15
D · Potential for more than minimal harm
2023-11-21
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
D · Potential for more than minimal harm
2023-11-21
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
D · Potential for more than minimal harm
2023-11-21
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-21
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-09-28
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-10-10
D · Potential for more than minimal harm
2023-06-29
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 2023-07-13
G · Actual harm
2023-03-20
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 2023-04-10
G · Actual harm
2023-03-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-10
D · Potential for more than minimal harm
2023-03-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-04-10
D · Potential for more than minimal harm
2022-11-18
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 2022-12-02
D · Potential for more than minimal harm
2022-11-18
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2022-12-02
D · Potential for more than minimal harm
2022-11-18
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 2022-12-07
C · Minimal harm
2022-11-18
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2022-12-02
Penalties and ownership
What sits behind the stars
Ownership
Brooks, Kiley
Operational/Managerial Control · Individual
Flanagan, Michael
Operational/Managerial Control · Individual
Flanagan, Michael
Corporate Officer · Individual
Steingraber, Brittney
Operational/Managerial Control · Individual
The Phares Company
Operational/Managerial Control · Organization
The Phares Company
5% Or Greater Security Interest · Organization
Tutera, Joseph
Operational/Managerial Control · Individual
Walnut Creek Management Company LLC
Operational/Managerial Control · Organization
Zaman, Asad
Operational/Managerial Control · Individual
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