Cycle 1
Health 2025-04-17 · Fire 2025-04-17
5 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Eldorado, IL
Eldorado Rehab & Healthcare
3-star overall rating with 4-star inspections with $23,989 in total fines with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1001 A Jefferson Street, Eldorado, IL
(618) 273-3353
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
59
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Wlc Management Firm
Operator or chain grouping
Approved since
1996-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
17 facilities
Chain averages 3 overall / 4 health / 1 staffing / 1 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
0.62
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.54
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.05
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.20
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.16
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
2.92
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.63
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.69
CMS adjusted RN staffing hours
Adjusted total hours
3.59
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,349
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.92
Composite VBP score used to determine payment impact.
Payment multiplier
0.9833
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.63
Baseline 20.88% · Performance 20.67% · Measure score 1.63 · Achievement 1.63 · Improvement 0.04
Healthcare-associated infections
0
Baseline 7.10% · Performance 9.00% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
7.57
Performance 32.73% · Measure score 7.57 · Achievement 7.57 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.36
Baseline 2.94 hours · Performance 3.18 hours · Measure score 0.36 · Achievement 0 · Improvement 0.36
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.43% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 74 · Observed rate 12.16% · Lower 95% interval 7.96% |
| Discharge to community | 42.3% |
50.57%
8.3 pts worse
|
No Different than the National Rate · Eligible stays 60 · Observed rate 35% · Lower 95% interval 33.34% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 51 · Denominator 51 |
| Falls with major injury | 1.96% |
0.77%
1.2 pts worse
|
Numerator 1 · Denominator 51 |
| Discharge self-care score | 69.57% |
53.69%
15.9 pts better
|
Numerator 16 · Denominator 23 |
| Discharge mobility score | 56.52% |
50.94%
5.6 pts better
|
Numerator 13 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 11.76% |
2.29%
9.5 pts worse
|
Numerator 6 · Denominator 51 · Adjusted rate 11.73% |
| Healthcare-associated infections requiring hospitalization | 9% |
7.12%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 43 · Observed rate 13.95% · Lower 95% interval 4.84% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 78 |
| Staff flu vaccination coverage | 81.52% |
42%
39.5 pts better
|
Numerator 75 · Denominator 92 |
| Discharge function score | 65.22% |
56.45%
8.8 pts better
|
Numerator 15 · Denominator 23 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 24 · Denominator 24 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 21.43% |
25.2%
3.8 pts worse
|
Numerator 6 · Denominator 28 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.3 |
2.0
1.3 pts worse
|
1.9
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 3.1 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.7 |
2.3
2.4 pts worse
|
1.8
2.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.7 · Observed 4.5 · Expected 1.6 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 4.5% |
3.3%
1.2 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 4.0% · Q3 3.9% · Q4 5.9% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 16.3% |
50.3%
34 pts better
|
11.4%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 10.6% · Q3 20.0% · Q4 10.6% · 4Q avg 16.3% |
| Percentage of long-stay residents who lose too much weight | 1.1% |
6.5%
5.4 pts better
|
5.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.0% · Q4 2.1% · 4Q avg 1.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.9% |
18.5%
12.4 pts worse
|
19.6%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.4% · Q2 31.2% · Q3 28.0% · Q4 34.0% · 4Q avg 30.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 34.7% |
22.8%
11.9 pts worse
|
16.7%
18 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.1% · Q2 37.8% · Q3 31.4% · Q4 33.3% · 4Q avg 34.7% · 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 | 19.9% |
17.2%
2.7 pts worse
|
16.3%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q3 25.2% · 4Q avg 19.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.3% |
15.0%
1.3 pts worse
|
14.9%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 9.1% · Q3 17.4% · Q4 34.8% · 4Q avg 16.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 6.2% |
1.1%
5.1 pts worse
|
1.0%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 7.6% · Q3 4.3% · Q4 2.7% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
1.7%
0.9 pts worse
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 4.0% · Q4 4.2% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.6% |
21.3%
1.3 pts worse
|
19.8%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 19.6% · Q3 22.9% · Q4 40.5% · 4Q avg 22.6% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
5.2%
0.8 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.2% · Q3 11.3% · Q4 2.1% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
68.8%
28.7 pts better
|
81.7%
15.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.1% · Q2 100.0% · Q3 97.7% · Q4 97.8% · 4Q avg 97.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.4% |
14.0%
1.6 pts better
|
12.0%
0.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.4% · Observed 12.0% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
2.3%
0.9 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q3 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 59.0% |
63.0%
4 pts worse
|
79.7%
20.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 59.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 43.2% |
26.2%
17 pts worse
|
23.9%
19.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 43.2% · Observed 40.0% · Expected 22.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-16 · Fire 2024-02-16
20 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-01-06 · Fire 2023-01-06
3 health deficiencies
Top issue: Environmental (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-17
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2025-05-09
F · Potential for more than minimal harm
2025-04-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-04-17
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-04-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-04-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-04-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-09
E · Potential for more than minimal harm
2024-02-16
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-16
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-16
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 2024-03-15
E · Potential for more than minimal harm
2024-02-16
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-16
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-15
E · Potential for more than minimal harm
2023-01-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-24
E · Potential for more than minimal harm
2023-01-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-01-24
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-26
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-12-24
D · Potential for more than minimal harm
2025-04-17
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 2025-05-07
D · Potential for more than minimal harm
2025-04-17
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 2025-05-07
D · Potential for more than minimal harm
2025-04-17
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-04-17
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-05-07
D · Potential for more than minimal harm
2024-08-30
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 2024-09-23
F · Potential for more than minimal harm
2024-02-16
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 2024-03-05
F · Potential for more than minimal harm
2024-02-16
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 2024-03-05
F · Potential for more than minimal harm
2024-02-16
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2024-03-05
E · Potential for more than minimal harm
2024-02-16
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-02-16
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-02-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-02-16
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-02-16
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 2024-03-05
D · Potential for more than minimal harm
2024-02-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-02-16
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-02-16
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-02-16
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 2024-03-05
D · Potential for more than minimal harm
2024-02-16
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 2024-03-05
D · Potential for more than minimal harm
2024-02-16
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-02-16
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 2024-03-05
D · Potential for more than minimal harm
2024-02-16
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 2024-03-05
D · Potential for more than minimal harm
2024-02-16
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 2024-03-05
D · Potential for more than minimal harm
2024-02-16
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-02-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-05
F · Potential for more than minimal harm
2023-12-29
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-01-11
D · Potential for more than minimal harm
2023-12-29
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 2024-01-11
E · Potential for more than minimal harm
2023-01-06
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 2023-01-24
Penalties and ownership
What sits behind the stars
$23,989
2024-02-16
Fine
Fine · fine $23,989
Fine
Ownership
Stout, Scott
5% Or Greater Indirect Ownership Interest · Individual
Wlc Management Firm LLC
5% Or Greater Direct Ownership Interest · Organization
Stout, Scott
Operational/Managerial Control · Individual
Stout, Scott
Corporate Officer · Individual
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