Cycle 1
Health 2024-06-06 · Fire 2024-06-06
11 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Crystal Lake, IL
Fair Oaks Health Care Center
4-star overall rating with 4-star inspections with 11 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
471 Terra Cotta Avenue, Crystal Lake, IL
(815) 455-0550
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
51
Certified beds
Average residents
41
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Wisconsin Illinois Senior Housing, Inc.
Operator or chain grouping
Approved since
1996-12-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 2 overall / 2 health / 4 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
1.47
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.25
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
3.26
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
4.98
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.72
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
4.31
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
1.16
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.35
CMS adjusted RN staffing hours
Adjusted total hours
4.56
CMS adjusted total nurse staffing hours
Case-mix index
1.50
Higher values indicate more complex resident acuity
RN turnover
69%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,739
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.70
Composite VBP score used to determine payment impact.
Payment multiplier
0.9829
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.18
Baseline 24.02% · Performance 22.85% · Measure score 1.18 · Achievement 0 · Improvement 1.18
Healthcare-associated infections
2.69
Baseline 5.83% · Performance 7.03% · Measure score 2.69 · Achievement 2.69 · Improvement 0
Total nurse turnover
1.79
Baseline 45.45% · Performance 56.36% · Measure score 1.79 · Achievement 1.79 · Improvement 0
Adjusted total nurse staffing
3.42
Baseline 4.90 hours · Performance 4.05 hours · Measure score 3.42 · Achievement 3.42 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.63% |
10.72%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 608 · Observed rate 12.83% · Lower 95% interval 10.69% |
| Discharge to community | 68.64% |
50.57%
18.1 pts better
|
Better than the National Rate · Eligible stays 566 · Observed rate 64.13% · Lower 95% interval 65.18% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 95.4% |
95.27%
0.1 pts better
|
Numerator 332 · Denominator 348 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 348 |
| Discharge self-care score | 32.97% |
53.69%
20.7 pts worse
|
Numerator 90 · Denominator 273 |
| Discharge mobility score | 28.94% |
50.94%
22 pts worse
|
Numerator 79 · Denominator 273 |
| Pressure ulcers or injuries, new or worsened | 2.59% |
2.29%
0.3 pts worse
|
Numerator 9 · Denominator 348 · Adjusted rate 2.91% |
| Healthcare-associated infections requiring hospitalization | 7.03% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 336 · Observed rate 6.55% · Lower 95% interval 4.78% |
| Staff COVID-19 vaccination coverage | 14.68% |
8.2%
6.5 pts better
|
Numerator 16 · Denominator 109 |
| Staff flu vaccination coverage | 68.6% |
42%
26.6 pts better
|
Numerator 83 · Denominator 121 |
| Discharge function score | 27.11% |
56.45%
29.3 pts worse
|
Numerator 74 · Denominator 273 |
| Transfer of health information to provider | 98.43% |
95.95%
2.5 pts better
|
Numerator 250 · Denominator 254 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 80 · Denominator 80 |
| Resident COVID-19 vaccinations up to date | 21.13% |
25.2%
4.1 pts worse
|
Numerator 41 · Denominator 194 |
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 | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 18.8% |
50.3%
31.5 pts better
|
11.4%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.8% |
| Percentage of long-stay residents who lose too much weight | 17.6% |
6.5%
11.1 pts worse
|
5.4%
12.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 2.9% |
18.5%
15.6 pts better
|
19.6%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
22.8%
22.8 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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 need for help with daily activities has increased | 24.1% |
15.0%
9.1 pts worse
|
14.9%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
1.1%
0.1 pts better
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
1.7%
0.4 pts worse
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.9% |
21.3%
6.4 pts better
|
19.8%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.9% |
| Percentage of long-stay residents with pressure ulcers | 13.2% |
5.2%
8 pts worse
|
5.1%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.9% |
68.8%
22.1 pts better
|
81.7%
9.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.2% · Q2 91.6% · Q3 90.9% · Q4 89.3% · 4Q avg 90.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.0% |
14.0%
7 pts better
|
12.0%
5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.0% · Observed 7.0% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.0% |
2.3%
0.3 pts better
|
1.6%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 0.6% · Q3 1.7% · Q4 2.8% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.7% |
63.0%
24.7 pts better
|
79.7%
8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.2% |
26.2%
7 pts better
|
23.9%
4.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.2% · Observed 21.0% · Expected 26.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-10 · Fire 2023-05-10
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
15 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Cycle 3
Health 2022-06-08 · Fire 2022-06-08
11 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-06-06
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-07-26
F · Potential for more than minimal harm
2024-06-06
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-07-26
F · Potential for more than minimal harm
2024-06-06
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-07-26
F · Potential for more than minimal harm
2024-06-06
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-08-14
F · Potential for more than minimal harm
2024-06-06
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-07-26
E · Potential for more than minimal harm
2024-06-06
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-07-26
E · Potential for more than minimal harm
2024-06-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-07-30
E · Potential for more than minimal harm
2024-06-06
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-07-26
F · Potential for more than minimal harm
2023-05-10
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-07-03
F · Potential for more than minimal harm
2023-05-10
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2023-07-03
F · Potential for more than minimal harm
2023-05-10
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2023-06-28
F · Potential for more than minimal harm
2023-05-10
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-07-15
F · Potential for more than minimal harm
2023-05-10
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-07-03
F · Potential for more than minimal harm
2023-05-10
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-07-03
F · Potential for more than minimal harm
2023-05-10
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-07-03
F · Potential for more than minimal harm
2023-05-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-28
F · Potential for more than minimal harm
2023-05-10
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-07-03
F · Potential for more than minimal harm
2023-05-10
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-07-03
F · Potential for more than minimal harm
2023-05-10
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-07-03
F · Potential for more than minimal harm
2023-05-10
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 2023-07-14
F · Potential for more than minimal harm
2023-05-10
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2023-07-03
E · Potential for more than minimal harm
2023-05-10
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-07-03
E · Potential for more than minimal harm
2023-05-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-03
F · Potential for more than minimal harm
2022-06-08
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2022-08-03
F · Potential for more than minimal harm
2022-06-08
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2022-08-03
F · Potential for more than minimal harm
2022-06-08
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-08-03
F · Potential for more than minimal harm
2022-06-08
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-08-03
F · Potential for more than minimal harm
2022-06-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-03
F · Potential for more than minimal harm
2022-06-08
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-08-03
C · Minimal harm
2022-06-08
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2022-08-03
C · Minimal harm
2022-06-08
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-08-03
Inspection history
Recent health citations
G · Actual harm
2025-10-09
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 2025-11-01
D · Potential for more than minimal harm
2025-03-10
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 2025-04-03
D · Potential for more than minimal harm
2025-03-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-03
E · Potential for more than minimal harm
2024-06-06
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 2024-07-15
E · Potential for more than minimal harm
2024-06-06
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 2024-07-15
D · Potential for more than minimal harm
2024-06-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-06-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-06-06
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 2024-07-15
D · Potential for more than minimal harm
2024-06-06
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 2024-07-15
D · Potential for more than minimal harm
2024-06-06
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 2024-07-15
D · Potential for more than minimal harm
2024-06-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-02-20
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 2024-03-18
D · Potential for more than minimal harm
2024-02-20
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 2024-03-20
E · Potential for more than minimal harm
2023-06-30
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-07-28
E · Potential for more than minimal harm
2023-06-30
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 2023-07-28
D · Potential for more than minimal harm
2023-06-30
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 2023-07-31
D · Potential for more than minimal harm
2023-05-10
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-05-10
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 2023-06-16
D · Potential for more than minimal harm
2023-05-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-05-10
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 2023-06-16
D · Potential for more than minimal harm
2023-05-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-05-10
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 2023-06-16
D · Potential for more than minimal harm
2023-05-10
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 2023-06-16
D · Potential for more than minimal harm
2023-05-10
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 2023-06-16
D · Potential for more than minimal harm
2023-05-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-16
F · Potential for more than minimal harm
2022-06-08
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 2022-07-05
D · Potential for more than minimal harm
2022-06-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-07-10
D · Potential for more than minimal harm
2022-06-08
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 2022-07-10
D · Potential for more than minimal harm
2022-06-08
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 2022-07-10
D · Potential for more than minimal harm
2022-06-08
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-07-10
D · Potential for more than minimal harm
2022-06-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-10
Penalties and ownership
What sits behind the stars
$0
2025-07-08
Payment Denial
Payment Denial · denial start 2025-08-06 · 44 days
44 day denial
Ownership
Carriage Healthcare Companies Inc
Operational/Managerial Control · Organization
Dupont, Lori
Corporate Director · Individual
Gehler, Miriam
Corporate Director · Individual
Kerwin, Andrew
Corporate Director · Individual
Kumar, Rajeev
Corporate Director · Individual
Lacke (Carrig), Karen
Corporate Director · Individual
Lynn, Nicholas
Corporate Director · Individual
Sherman, Stephanie
Operational/Managerial Control · Individual
Siebel, Robert
Operational/Managerial Control · Individual
Sweis, Nadeen
Operational/Managerial Control · Individual
Zaio, Noreen
Operational/Managerial Control · Individual
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