Cycle 1
Health 2024-06-05 · Fire 2024-06-05
19 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Crystal Lake, IL
Crystal Pines Rehab & Hcc
1-star overall rating with 2-star inspections with abuse icon flag with $52,795 in total fines with 19 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
335 North Illinois Avenue, Crystal Lake, IL
(815) 459-7791
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
110
Certified beds
Average residents
77
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Tutera Senior Living & Health Care
Operator or chain grouping
Approved since
1973-11-01
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
0.80
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.53
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.96
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.29
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.02
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.65
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.73
CMS adjusted RN staffing hours
Adjusted total hours
3.00
CMS adjusted total nurse staffing hours
Case-mix index
1.50
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
8,544
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.37
Composite VBP score used to determine payment impact.
Payment multiplier
0.9841
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.33% · Performance 22.87% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
7.91
Baseline 11.59% · Performance 6.04% · Measure score 7.91 · Achievement 5.99 · Improvement 7.91
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
0
Baseline 3.42 hours · Performance 2.91 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13% |
10.72%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 88 · Observed rate 21.59% · Lower 95% interval 9.25% |
| Discharge to community | 41.15% |
50.57%
9.4 pts worse
|
No Different than the National Rate · Eligible stays 95 · Observed rate 30.53% · Lower 95% interval 31.74% |
| Medicare spending per beneficiary | 1.17 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.33% |
95.27%
3.1 pts better
|
Numerator 59 · Denominator 60 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 60 |
| Discharge self-care score | 29.03% |
53.69%
24.7 pts worse
|
Numerator 9 · Denominator 31 |
| Discharge mobility score | 32.26% |
50.94%
18.7 pts worse
|
Numerator 10 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 60 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.04% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 57 · Observed rate 3.51% · Lower 95% interval 3.3% |
| Staff COVID-19 vaccination coverage | 13.16% |
8.2%
5 pts better
|
Numerator 10 · Denominator 76 |
| Staff flu vaccination coverage | 61.29% |
42%
19.3 pts better
|
Numerator 57 · Denominator 93 |
| Discharge function score | 35.48% |
56.45%
21 pts worse
|
Numerator 11 · Denominator 31 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 21 · Denominator 21 |
| Transfer of health information to patient | 95% |
96.28%
1.3 pts worse
|
Numerator 19 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 11.54% |
25.2%
13.7 pts worse
|
Numerator 3 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.0
0.2 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.5 · Expected 2.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
2.3
1.2 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.2 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
89.6%
10 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.6% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
91.6%
8.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.9% |
3.3%
0.6 pts worse
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 4.1% · Q3 2.9% · Q4 4.5% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.9% |
50.3%
42.4 pts better
|
11.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 11.9% · Q3 6.1% · Q4 4.0% · 4Q avg 7.9% |
| Percentage of long-stay residents who lose too much weight | 9.7% |
6.5%
3.2 pts worse
|
5.4%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 12.5% · Q3 12.7% · Q4 9.5% · 4Q avg 9.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.9% |
18.5%
0.4 pts worse
|
19.6%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 16.2% · Q3 18.2% · Q4 22.2% · 4Q avg 18.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.1% |
22.8%
5.7 pts better
|
16.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 14.5% · Q3 18.4% · Q4 20.0% · 4Q avg 17.1% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 33.1% |
17.2%
15.9 pts worse
|
16.3%
16.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 33.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.5% |
15.0%
7.5 pts worse
|
14.9%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.4% · Q2 23.4% · Q3 24.6% · Q4 18.3% · 4Q avg 22.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
1.1%
0.9 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.3% |
1.7%
1.6 pts worse
|
1.7%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 4.3% · Q3 6.0% · Q4 1.5% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.4% |
21.3%
8.1 pts worse
|
19.8%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.5% · Q2 35.7% · Q3 29.1% · Q4 17.3% · 4Q avg 29.4% |
| Percentage of long-stay residents with pressure ulcers | 8.6% |
5.2%
3.4 pts worse
|
5.1%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 9.9% · Q3 6.8% · Q4 7.8% · 4Q avg 8.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.6% |
68.8%
9.8 pts better
|
81.7%
3.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 62.3% · Q2 78.3% · Q3 87.9% · Q4 86.6% · 4Q avg 78.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.5% |
14.0%
4.5 pts better
|
12.0%
2.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.5% · Observed 11.4% · Expected 13.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
2.3%
1.5 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.2% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 56.7% |
63.0%
6.3 pts worse
|
79.7%
23 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 56.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.9% |
26.2%
0.7 pts worse
|
23.9%
3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.9% · Observed 40.9% · Expected 36.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-19 · Fire 2023-07-19
18 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-08-24 · Fire 2022-08-24
10 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-06-05
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-07-03
F · Potential for more than minimal harm
2024-06-05
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2024-07-03
F · Potential for more than minimal harm
2024-06-05
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-07-03
F · Potential for more than minimal harm
2024-06-05
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-07-03
F · Potential for more than minimal harm
2024-06-05
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-07-03
F · Potential for more than minimal harm
2024-06-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-03
F · Potential for more than minimal harm
2024-06-05
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-07-03
F · Potential for more than minimal harm
2024-06-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-03
F · Potential for more than minimal harm
2024-06-05
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 2024-07-03
E · Potential for more than minimal harm
2024-06-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-07-03
E · Potential for more than minimal harm
2024-06-05
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-07-03
E · Potential for more than minimal harm
2024-06-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-03
E · Potential for more than minimal harm
2024-06-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-07-03
E · Potential for more than minimal harm
2024-06-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-07-03
E · Potential for more than minimal harm
2024-06-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-07-03
F · Potential for more than minimal harm
2023-07-19
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-08-19
F · Potential for more than minimal harm
2023-07-19
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-08-19
F · Potential for more than minimal harm
2023-07-19
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-08-19
F · Potential for more than minimal harm
2023-07-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-19
F · Potential for more than minimal harm
2023-07-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-19
E · Potential for more than minimal harm
2023-07-19
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 2023-08-19
E · Potential for more than minimal harm
2023-07-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-19
E · Potential for more than minimal harm
2023-07-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-19
E · Potential for more than minimal harm
2023-07-19
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-08-19
E · Potential for more than minimal harm
2023-07-19
K791 · Miscellaneous Deficiencies
Fire Safety
Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency.
Corrected 2023-08-19
E · Potential for more than minimal harm
2023-07-19
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-08-19
F · Potential for more than minimal harm
2022-08-24
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-09-20
F · Potential for more than minimal harm
2022-08-24
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-09-20
F · Potential for more than minimal harm
2022-08-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-09-20
F · Potential for more than minimal harm
2022-08-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-09-20
E · Potential for more than minimal harm
2022-08-24
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2022-09-20
E · Potential for more than minimal harm
2022-08-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-09-20
E · Potential for more than minimal harm
2022-08-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-09-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-03
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-12-31
D · Potential for more than minimal harm
2025-11-21
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 2025-12-15
G · Actual harm
2025-10-14
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 2025-11-03
D · Potential for more than minimal harm
2025-08-20
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 2025-08-29
D · Potential for more than minimal harm
2025-04-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-16
F · Potential for more than minimal harm
2025-04-15
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2025-05-02
F · Potential for more than minimal harm
2025-04-15
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-05-02
F · Potential for more than minimal harm
2025-04-15
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 2025-06-07
D · Potential for more than minimal harm
2025-02-24
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-01-08
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 2025-01-16
D · Potential for more than minimal harm
2025-01-08
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-12-11
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 2025-01-28
D · Potential for more than minimal harm
2024-11-27
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 2024-12-16
J · Immediate jeopardy
2024-11-14
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 2024-11-11
D · Potential for more than minimal harm
2024-11-14
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 2024-12-16
D · Potential for more than minimal harm
2024-07-18
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 2024-08-05
G · Actual harm
2024-06-05
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 2024-06-25
E · Potential for more than minimal harm
2024-06-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-25
E · Potential for more than minimal harm
2024-06-05
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 2024-06-05
E · Potential for more than minimal harm
2024-06-05
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-06-25
D · Potential for more than minimal harm
2024-06-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-25
D · Potential for more than minimal harm
2024-06-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-06-25
D · Potential for more than minimal harm
2024-06-05
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 2024-06-25
D · Potential for more than minimal harm
2024-06-05
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 2024-06-25
D · Potential for more than minimal harm
2024-06-05
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-06-25
D · Potential for more than minimal harm
2024-06-05
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-06-05
D · Potential for more than minimal harm
2024-06-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-25
D · Potential for more than minimal harm
2024-03-26
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 2024-03-09
G · Actual harm
2023-07-19
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 2023-08-02
G · Actual harm
2023-07-19
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-08-02
F · Potential for more than minimal harm
2023-07-19
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-08-02
F · Potential for more than minimal harm
2023-07-19
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-08-02
F · Potential for more than minimal harm
2023-07-19
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 2023-08-02
F · Potential for more than minimal harm
2023-07-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-02
E · Potential for more than minimal harm
2023-07-19
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2023-08-02
D · Potential for more than minimal harm
2023-07-19
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 2023-08-02
D · Potential for more than minimal harm
2023-07-19
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 2023-08-02
D · Potential for more than minimal harm
2023-03-30
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 2023-04-12
D · Potential for more than minimal harm
2023-03-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-13
F · Potential for more than minimal harm
2022-08-24
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 2022-09-08
F · Potential for more than minimal harm
2022-08-24
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-09-08
E · Potential for more than minimal harm
2022-08-24
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2022-09-08
D · Potential for more than minimal harm
2022-08-24
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 2022-09-08
D · Potential for more than minimal harm
2022-08-24
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 2022-09-08
D · Potential for more than minimal harm
2022-08-24
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-09-08
D · Potential for more than minimal harm
2022-08-24
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-09-08
D · Potential for more than minimal harm
2022-08-24
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 2022-09-08
Penalties and ownership
What sits behind the stars
$16,801
2024-11-14
Fine
Fine · fine $16,801
Fine
$14,050
2024-06-05
Fine
Fine · fine $14,050
Fine
$0
2024-06-05
Payment Denial
Payment Denial · denial start 2024-07-05 · 31 days
31 day denial
$21,944
2023-07-19
Fine
Fine · fine $21,944
Fine
Ownership
Tutera, Joseph
5% Or Greater Direct Ownership Interest · Individual
Brooks, Kiley
Corporate Officer · Individual
Gannon, Jeff
Corporate Officer · Individual
Standish, James
Operational/Managerial Control · Individual
Tutera Investments, LLC
5% Or Greater Direct Ownership Interest · Organization
Walnut Creek Management Company LLC
Operational/Managerial Control · Organization
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