Cycle 1
Health 2024-08-07 · Fire 2024-08-07
24 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Pekin, IL
Timbercreek Rehab and Health Care Center
1-star overall rating with 1-star inspections with abuse icon flag with $213,731 in total fines with 23 recent health deficiencies
2220 State Street, Pekin, IL
(309) 347-1110
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
202
Certified beds
Average residents
84
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Petersen Health Care
Operator or chain grouping
Approved since
1974-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 2 overall / 2 health / 1 staffing / 2 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
0.23
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.25
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.47
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.22
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
2.89
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.19
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
0.21
CMS adjusted RN staffing hours
Adjusted total hours
3.17
CMS adjusted total nurse staffing hours
Case-mix index
1.50
Higher values indicate more complex resident acuity
RN turnover
83%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
67%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,693
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.46
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
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
2.19
Baseline 7.37% · Performance 7.18% · Measure score 2.19 · Achievement 2.19 · Improvement 0.29
Total nurse turnover
2.78
Baseline 67.86% · Performance 53.73% · Measure score 2.78 · Achievement 2.43 · Improvement 2.78
Adjusted total nurse staffing
0.87
Baseline 2.57 hours · Performance 3.01 hours · Measure score 0.87 · Achievement 0 · Improvement 0.87
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.76% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 49 · Observed rate 12.24% · Lower 95% interval 7.51% |
| Discharge to community | 40.68% |
50.57%
9.9 pts worse
|
No Different than the National Rate · Eligible stays 41 · Observed rate 31.71% · Lower 95% interval 28.08% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.14% |
95.27%
1.9 pts better
|
Numerator 34 · Denominator 35 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 35 |
| Discharge self-care score | 13.64% |
53.69%
40 pts worse
|
Numerator 3 · Denominator 22 |
| Discharge mobility score | 4.55% |
50.94%
46.4 pts worse
|
Numerator 1 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 35 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.18% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 25 · Observed rate 8% · Lower 95% interval 4.16% |
| Staff COVID-19 vaccination coverage | 7.92% |
8.2%
0.3 pts worse
|
Numerator 8 · Denominator 101 |
| Staff flu vaccination coverage | 25.89% |
42%
16.1 pts worse
|
Numerator 29 · Denominator 112 |
| Discharge function score | 4.55% |
56.45%
51.9 pts worse
|
Numerator 1 · Denominator 22 |
| 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 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 20 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.6 |
2.0
1.6 pts worse
|
1.9
1.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.6 · Observed 3.4 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
2.3
0.4 pts worse
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 3.0 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 34.1% |
89.6%
55.5 pts worse
|
93.4%
59.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 58.0% · Q2 25.3% · Q3 26.1% · Q4 27.2% · 4Q avg 34.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 49.0% |
91.6%
42.6 pts worse
|
95.5%
46.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 49.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.4% |
3.3%
2.1 pts worse
|
3.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 5.5% · Q3 6.5% · Q4 7.4% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 15.0% |
50.3%
35.3 pts better
|
11.4%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 14.6% · Q3 12.3% · Q4 16.9% · 4Q avg 15.0% |
| Percentage of long-stay residents who lose too much weight | 10.9% |
6.5%
4.4 pts worse
|
5.4%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 15.4% · Q3 16.5% · Q4 9.2% · 4Q avg 10.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.7% |
18.5%
10.2 pts worse
|
19.6%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.9% · Q2 23.8% · Q3 33.8% · Q4 28.4% · 4Q avg 28.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.7% |
22.8%
5.1 pts better
|
16.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 18.5% · Q3 19.6% · Q4 14.5% · 4Q avg 17.7% · 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 | 22.6% |
17.2%
5.4 pts worse
|
16.3%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 28.0% · Q3 20.7% · Q4 16.7% · 4Q avg 22.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.7% |
15.0%
4.7 pts worse
|
14.9%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 20.0% · Q3 22.8% · Q4 16.9% · 4Q avg 19.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
1.1%
0.5 pts worse
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 2.3% · Q3 2.5% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.9% |
1.7%
1.2 pts worse
|
1.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 4.5% · Q3 3.3% · Q4 1.3% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.7% |
21.3%
3.4 pts worse
|
19.8%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 30.4% · Q3 20.8% · Q4 27.5% · 4Q avg 24.7% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
5.2%
0.6 pts worse
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 5.1% · Q3 6.6% · Q4 5.3% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 25.8% |
68.8%
43 pts worse
|
81.7%
55.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 48.9% · Q2 17.9% · Q3 12.9% · Q4 16.7% · 4Q avg 25.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.7% |
14.0%
0.3 pts better
|
12.0%
1.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.7% · Observed 15.2% · Expected 12.3% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · 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 | 12.2% |
63.0%
50.8 pts worse
|
79.7%
67.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 12.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.4% |
26.2%
3.2 pts worse
|
23.9%
5.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.4% · Observed 33.3% · Expected 27.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-21 · Fire 2023-09-21
28 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-10-05 · Fire 2022-10-05
21 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-12-13
D · Potential for more than minimal harm
2025-12-06
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 2025-12-13
G · Actual harm
2025-08-25
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 2025-09-08
F · Potential for more than minimal harm
2025-08-25
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-08-25
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-07-16
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 2025-08-05
E · Potential for more than minimal harm
2025-06-11
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 2025-06-23
D · Potential for more than minimal harm
2025-04-28
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 2025-05-15
E · Potential for more than minimal harm
2025-04-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-04-04
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 2025-04-16
G · Actual harm
2024-12-12
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 2024-12-20
D · Potential for more than minimal harm
2024-11-08
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-11-27
D · Potential for more than minimal harm
2024-11-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-27
D · Potential for more than minimal harm
2024-11-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-27
G · Actual harm
2024-10-04
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-24
F · Potential for more than minimal harm
2024-08-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-23
F · Potential for more than minimal harm
2024-08-07
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-08-29
E · Potential for more than minimal harm
2024-08-07
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 2024-09-23
E · Potential for more than minimal harm
2024-08-07
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 2024-09-23
E · Potential for more than minimal harm
2024-08-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-23
D · Potential for more than minimal harm
2024-08-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-08-07
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-08-07
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-08-07
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 2024-08-29
D · Potential for more than minimal harm
2024-08-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-23
D · Potential for more than minimal harm
2024-08-07
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 2024-08-29
D · Potential for more than minimal harm
2024-08-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-08-07
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 2024-09-23
D · Potential for more than minimal harm
2024-08-07
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 2024-09-23
K · Immediate jeopardy
2024-07-25
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 2024-08-23
D · Potential for more than minimal harm
2024-07-25
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 2024-08-23
G · Actual harm
2024-04-28
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 2024-05-16
G · Actual harm
2024-04-28
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-05-16
F · Potential for more than minimal harm
2024-04-07
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-04-08
E · Potential for more than minimal harm
2024-03-13
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 2024-03-27
G · Actual harm
2024-01-04
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 2024-01-16
D · Potential for more than minimal harm
2023-11-29
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 2023-12-09
G · Actual harm
2023-11-17
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 2023-12-01
G · Actual harm
2023-09-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-06
F · Potential for more than minimal harm
2023-09-21
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-10-06
F · Potential for more than minimal harm
2023-09-21
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2023-10-06
F · Potential for more than minimal harm
2023-09-21
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-10-06
F · Potential for more than minimal harm
2023-09-21
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-10-06
E · Potential for more than minimal harm
2023-09-21
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 2023-10-06
E · Potential for more than minimal harm
2023-09-21
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 2023-10-06
E · Potential for more than minimal harm
2023-09-21
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-09-21
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 2023-10-06
D · Potential for more than minimal harm
2023-09-21
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 2023-10-06
D · Potential for more than minimal harm
2023-09-21
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-09-21
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-09-21
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 2023-10-06
D · Potential for more than minimal harm
2023-09-21
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-09-21
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 2023-10-06
D · Potential for more than minimal harm
2023-09-21
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 2023-10-06
C · Minimal harm
2023-09-21
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-10-06
F · Potential for more than minimal harm
2023-08-17
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 2023-09-01
F · Potential for more than minimal harm
2023-08-17
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-08-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-01
F · Potential for more than minimal harm
2023-08-17
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-08-17
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 2023-09-05
D · Potential for more than minimal harm
2023-08-17
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 2023-09-01
D · Potential for more than minimal harm
2023-08-17
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 2023-09-01
D · Potential for more than minimal harm
2023-08-17
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 2023-09-01
D · Potential for more than minimal harm
2023-08-17
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 2023-09-01
D · Potential for more than minimal harm
2023-08-17
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2023-09-01
B · Minimal harm
2023-08-17
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 2023-09-01
D · Potential for more than minimal harm
2023-03-28
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 2023-04-07
D · Potential for more than minimal harm
2023-03-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-03-28
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 2023-04-07
D · Potential for more than minimal harm
2023-03-28
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 2023-04-07
G · Actual harm
2022-10-05
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 2022-10-19
D · Potential for more than minimal harm
2022-10-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-10-19
D · Potential for more than minimal harm
2022-10-05
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 2022-10-19
Penalties and ownership
What sits behind the stars
$16,965
2024-12-12
Fine
Fine · fine $16,965
Fine
$49,220
2024-10-04
Fine
Fine · fine $49,220
Fine
$52,679
2024-07-25
Fine
Fine · fine $52,679
Fine
$0
2024-07-25
Payment Denial
Payment Denial · denial start 2024-08-29 · 25 days
25 day denial
$22,950
2024-03-13
Fine
Fine · fine $22,950
Fine
$0
2024-03-13
Payment Denial
Payment Denial · denial start 2024-05-07 · 9 days
9 day denial
$62,654
2023-11-17
Fine
Fine · fine $62,654
Fine
$0
2023-11-17
Payment Denial
Payment Denial · denial start 2023-12-15 · 32 days
32 day denial
$9,263
2023-09-21
Fine
Fine · fine $9,263
Fine
Ownership
Petersen, Mark
5% Or Greater Direct Ownership Interest · Individual
Petersen, Mark
Corporate Director · Individual
Woodle, Jeremy
Operational/Managerial Control · Individual
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