Cycle 1
Health 2024-08-01 · Fire 2024-08-01
14 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Bloomington, IL
Luther Oaks
4-star overall rating with 3-star inspections with $10,000 in total fines with 14 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
601 Lutz Road, Bloomington, IL
(309) 664-5940
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
19
Certified beds
Average residents
17
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2017-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
1.46
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.43
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.60
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
4.49
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.89
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
4.11
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
1.13
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
1.49
CMS adjusted RN staffing hours
Adjusted total hours
4.57
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
66%
Annual nurse turnover · state 46% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.2% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 43 · Observed rate 0% · Lower 95% interval 5.81% |
| Discharge to community | 59.2% |
50.57%
8.6 pts better
|
No Different than the National Rate · Eligible stays 34 · Observed rate 58.82% · Lower 95% interval 45.99% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 83.33% |
95.27%
11.9 pts worse
|
Numerator 20 · Denominator 24 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 24 |
| Discharge self-care score | 52.38% |
53.69%
1.3 pts worse
|
Numerator 11 · Denominator 21 |
| Discharge mobility score | 61.9% |
50.94%
11 pts better
|
Numerator 13 · Denominator 21 |
| Pressure ulcers or injuries, new or worsened | 4.17% |
2.29%
1.9 pts worse
|
Numerator 1 · Denominator 24 · Adjusted rate 3.89% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 25% |
8.2%
16.8 pts better
|
Numerator 13 · Denominator 52 |
| Staff flu vaccination coverage | 68.83% |
42%
26.8 pts better
|
Numerator 53 · Denominator 77 |
| Discharge function score | 57.14% |
56.45%
0.7 pts better
|
Numerator 12 · Denominator 21 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
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 | 12.7% |
3.3%
9.4 pts worse
|
3.3%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 18.4% |
50.3%
31.9 pts better
|
11.4%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.4% |
| Percentage of long-stay residents who lose too much weight | 2.9% |
6.5%
3.6 pts better
|
5.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.1% |
18.5%
1.4 pts better
|
19.6%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 26.9% |
22.8%
4.1 pts worse
|
16.7%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.4% |
17.2%
3.8 pts better
|
16.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.8% |
15.0%
3.2 pts better
|
14.9%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.1%
1.1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.2% |
21.3%
1.9 pts worse
|
19.8%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.2% |
| Percentage of long-stay residents with pressure ulcers | 1.1% |
5.2%
4.1 pts better
|
5.1%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
68.8%
31.2 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.8% |
63.0%
32.8 pts better
|
79.7%
16.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.8% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-02 · Fire 2023-08-02
1 health deficiencies
Top issue: Infection Control (1 deficiency)
13 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Cycle 3
Health 2022-06-22 · Fire 2022-06-22
14 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
10 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-16
F · Potential for more than minimal harm
2023-08-02
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-09-07
F · Potential for more than minimal harm
2023-08-02
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2023-09-07
F · Potential for more than minimal harm
2023-08-02
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-09-30
F · Potential for more than minimal harm
2023-08-02
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-09-30
F · Potential for more than minimal harm
2023-08-02
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-09-18
F · Potential for more than minimal harm
2023-08-02
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-09-07
F · Potential for more than minimal harm
2023-08-02
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-08-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-08-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-08-02
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-12-06
F · Potential for more than minimal harm
2023-08-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-08-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-05
E · Potential for more than minimal harm
2023-08-02
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 2023-08-28
F · Potential for more than minimal harm
2022-06-22
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2022-08-15
F · Potential for more than minimal harm
2022-06-22
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2022-08-15
F · Potential for more than minimal harm
2022-06-22
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2022-08-15
F · Potential for more than minimal harm
2022-06-22
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-08-15
F · Potential for more than minimal harm
2022-06-22
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-08-15
F · Potential for more than minimal harm
2022-06-22
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2022-08-08
F · Potential for more than minimal harm
2022-06-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-08-15
F · Potential for more than minimal harm
2022-06-22
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-07-19
F · Potential for more than minimal harm
2022-06-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-07-21
D · Potential for more than minimal harm
2022-06-22
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-08-15
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-11-05
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 2025-12-05
D · Potential for more than minimal harm
2025-11-05
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 2025-12-05
F · Potential for more than minimal harm
2024-08-01
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 2024-09-15
F · Potential for more than minimal harm
2024-08-01
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 2024-09-15
F · Potential for more than minimal harm
2024-08-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-15
D · Potential for more than minimal harm
2024-08-01
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 2024-09-15
D · Potential for more than minimal harm
2024-08-01
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-09-15
D · Potential for more than minimal harm
2024-08-01
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-09-15
D · Potential for more than minimal harm
2024-08-01
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-09-15
D · Potential for more than minimal harm
2024-08-01
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-09-15
D · Potential for more than minimal harm
2024-08-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-15
D · Potential for more than minimal harm
2024-08-01
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 2024-09-15
D · Potential for more than minimal harm
2024-08-01
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 2024-09-15
D · Potential for more than minimal harm
2024-08-01
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-09-15
D · Potential for more than minimal harm
2024-02-17
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 2024-02-21
G · Actual harm
2024-01-29
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 2024-02-21
D · Potential for more than minimal harm
2024-01-29
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 2024-02-21
E · Potential for more than minimal harm
2023-08-02
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-09-11
G · Actual harm
2023-04-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-18
G · Actual harm
2023-04-24
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 2023-05-18
E · Potential for more than minimal harm
2023-04-24
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-05-18
D · Potential for more than minimal harm
2023-04-24
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 2023-05-18
D · Potential for more than minimal harm
2023-04-24
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-05-18
D · Potential for more than minimal harm
2023-04-24
F659 · Resident Assessment and Care Planning Deficiencies
Health
Provide care by qualified persons according to each resident's written plan of care.
Corrected 2023-05-18
D · Potential for more than minimal harm
2023-04-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-18
D · Potential for more than minimal harm
2023-04-24
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-05-18
F · Potential for more than minimal harm
2022-06-22
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 2022-07-07
D · Potential for more than minimal harm
2022-06-22
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2022-07-07
D · Potential for more than minimal harm
2022-06-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-07-07
Penalties and ownership
What sits behind the stars
$10,000
2025-09-11
Fine
Fine · fine $10,000
Fine
Ownership
Black, Terri
Corporate Director · Individual
Black, Terri
W-2 Managing Employee · Individual
Kibler, John
Corporate Director · Individual
Lutheran Life Communities
Operational/Managerial Control · Organization
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