Carlinville Rehab & HCC
751 North Oak Street, Carlinville, IL 62626 · Macoupin County · 98 certified beds · avg 75 residents/day · certified since Aug 31, 1982
Abuse citation flag (CMS)
Part of chain: TUTERA SENIOR LIVING & HEALTH CARE (25 facilities, chain avg rating 2.0★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Dec 18, 2025 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 15, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 3, 2024 · F-0602 · triggered by a complaint
The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds.
Why it matters: Residents can lose money, jewelry, or cherished possessions to theft or misuse.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 17, 2024 (Past Non-Compliance)
▲ Actual harm, one-off · Jul 1, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 29, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jul 1, 2024 · F-0697
The facility did not provide safe and appropriate pain management for a resident who needed it.
Why it matters: Untreated pain causes needless suffering and can lead to depression, poor sleep, and declining health.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 2, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · May 29, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 29, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jul 27, 2023 · F-0690
The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Why it matters: Poor continence and catheter care leads to infections, skin breakdown, and loss of dignity.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 23, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (38)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 17, 2026 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Dec 18, 2025 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jun 26, 2025 | F · Potential for harm, facility-wide | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Jun 26, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jun 26, 2025 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Jun 26, 2025 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Jun 26, 2025 | E · Potential for harm, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jun 26, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jun 26, 2025 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Jun 26, 2025 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Jun 26, 2025 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Jun 26, 2025 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Jun 26, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 30, 2025 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Sep 3, 2024 | ▲ G · Actual harm, one-off | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint |
| Jul 1, 2024 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jul 1, 2024 | ▲ G · Actual harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Jul 1, 2024 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Jul 1, 2024 | E · Potential for harm, repeated | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Jul 1, 2024 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Jul 1, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jul 1, 2024 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jul 1, 2024 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Jul 1, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Jul 1, 2024 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Jul 1, 2024 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Jul 1, 2024 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Jul 1, 2024 | D · Potential for harm, one-off | The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. |
| Jul 1, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| Jul 1, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Jul 1, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| May 29, 2024 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| May 29, 2024 | D · Potential for harm, one-off | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint |
| Sep 26, 2023 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Jul 27, 2023 | ▲ G · Actual harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Jul 27, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Jul 27, 2023 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jul 27, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (16 → 11).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 5 | 1 | G ▲ |
| 2024 | 19 | 4 | G ▲ |
| 2025 | 13 | 1 | G ▲ |
| 2026 | 1 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $137,709, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| May 29, 2024 | Fine | $137,709 |
| May 29, 2024 | Payment Denial | 69 days from Jun 21, 2024 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Illinois avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.35 | 2.99 | 3.95 | bottom 26% in Illinois; bottom 2% in the U.S. |
| Registered Nurse hours | 0.33 | 0.63 | 0.69 | bottom 21% in Illinois; bottom 13% in the U.S. |
| Weekend total nurse staffing | 1.99 | 2.67 | 3.50 | bottom 20% in Illinois; bottom 2% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.33 | 0.56 | 0.48 | bottom 26% in Illinois; bottom 38% in the U.S. |
| Total nursing staff turnover (%) | 62.9 | 44.5 | 45.8 | bottom 10% in Illinois; bottom 12% in the U.S. |
| RN turnover (%) | 60.0 | 41.8 | 42.9 | bottom 21% in Illinois; bottom 22% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.14, RN 0.44, weekend 2.66. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 4/5 · short-stay residents: 1/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| JCT Family Limited Partnership | Organization | Direct Ownership Interest | NOT APPLICABLE | 09/25/2017 |
| Tutera Investments, LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 04/25/2017 |
| Bloom, Randall | Individual | Corporate Officer | NOT APPLICABLE | 04/25/2017 |
| Bloom, Randall | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/25/2017 |
| Bloom, Randall | Individual | ADP of the SNF | NOT APPLICABLE | 04/25/2017 |
| Brooks, Kiley | Individual | Corporate Officer | NOT APPLICABLE | 06/01/2013 |
| Brooks, Kiley | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/25/2017 |
| Brooks, Kiley | Individual | ADP of the SNF | NOT APPLICABLE | 04/25/2017 |
| Buchanan, Pamela | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2025 |
| Buchanan, Pamela | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2025 |
| Dominic Frank Tutera 2016 Irrv Tr | Organization | Limited Partnership Interest | NOT APPLICABLE | 04/25/2017 |
| Flanagan, Michael | Individual | Trustee of the SNF | NOT APPLICABLE | 10/11/2011 |
| Hannah Marie Tutera 2013 Irrevocable Trust | Organization | Limited Partnership Interest | NOT APPLICABLE | 04/25/2017 |
| Johnson, Nicole | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2025 |
| Joseph Charles Tutera Jr 2019 Irrv Tr | Organization | Limited Partnership Interest | NOT APPLICABLE | 06/27/2019 |
| Laura Cirese Tutera 2011 Irrevocable Trust | Organization | Limited Partnership Interest | NOT APPLICABLE | 04/25/2017 |
| Marshal, Ericka | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2025 |
| Marshal, Ericka | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2025 |
| Ti-Carlinville, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/05/2019 |
| Tutera, Joseph | Individual | Corporate Director | NOT APPLICABLE | 02/01/2008 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What safeguards do you have to protect residents' money and belongings, and what happens when something goes missing?"
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "Could I join residents for a meal to see the food quality and temperature for myself?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Hallmark HC of Carlinville | 0.4 mi | Carlinville, IL | ★★☆☆☆ | 3/5 | |
| Lakeside Health & Rehab Center | 0.7 mi | Carlinville, IL | ★☆☆☆☆ | 2/5 | |
| Gillespie Health & Rehab Ctr | 12.9 mi | Gillespie, IL | ★★★★☆ | 4/5 | |
| Litchfield Health & Rehab Center | 15.0 mi | Litchfield, IL | ★★★★☆ | 4/5 | |
| Avenues at Litchfield | 15.3 mi | Litchfield, IL | ★★★★☆ | 4/5 | |
| Sunrise Skilled Nur & Rehab | 15.6 mi | Virden, IL | ★★☆☆☆ | 3/5 | |
| Staunton Health and Rehab Ctr | 19.5 mi | Staunton, IL | ★★☆☆☆ | 3/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 145454.