Coulterville Rehab & HCC
13138 State Route 13, Coulterville, IL 62237 · Randolph County · 75 certified beds · avg 69 residents/day · certified since May 1, 2000
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)
▲ Immediate jeopardy, one-off · Apr 7, 2026 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Apr 9, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jul 21, 2023 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
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 15, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (12)
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 7, 2026 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Apr 7, 2026 | E · Potential for harm, repeated | 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 15, 2025 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Aug 30, 2024 | 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. |
| Aug 30, 2024 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Jul 21, 2023 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jul 21, 2023 | F · Potential for harm, facility-wide | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| Jul 21, 2023 | 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. |
| Jul 21, 2023 | F · Potential for harm, facility-wide | 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 21, 2023 | E · Potential for harm, repeated | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Jul 21, 2023 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Jul 21, 2023 | 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. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (7 → 2).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 7 | 1 | G ▲ |
| 2024 | 2 | 0 | F |
| 2025 | 1 | 0 | E |
| 2026 | 2 | 1 | J ▲ |
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 $113,818.
| Date | Type | Amount / length |
|---|---|---|
| Apr 7, 2026 | Fine | $113,818 |
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) | 2.64 | 2.99 | 3.95 | bottom 49% in Illinois; bottom 5% in the U.S. |
| Registered Nurse hours | 0.35 | 0.63 | 0.69 | bottom 24% in Illinois; bottom 15% in the U.S. |
| Weekend total nurse staffing | 2.38 | 2.67 | 3.50 | bottom 49% in Illinois; bottom 6% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.23 | 0.56 | 0.48 | bottom 12% in Illinois; bottom 18% in the U.S. |
| Total nursing staff turnover (%) | 47.1 | 44.5 | 45.8 | bottom 41% in Illinois; bottom 44% in the U.S. |
| RN turnover (%) | 33.3 | 41.8 | 42.9 | top 35% in Illinois; top 33% 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 3.11, RN 0.41, weekend 2.80. 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: 3/5 · long-stay residents: 4/5 · short-stay residents: 1/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Dominic Frank Tutera 2016 Irrv Tr | Organization | Indirect Ownership Interest | NOT APPLICABLE | 07/18/2015 |
| Hannah Marie Tutera 2013 Irrevocable Trust | Organization | Indirect Ownership Interest | NOT APPLICABLE | 11/20/2013 |
| JCT Family Limited Partnership | Organization | Direct Ownership Interest | NOT APPLICABLE | 11/20/2013 |
| JCT Investments, LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 11/20/2013 |
| Joseph Charles Tutera Jr 2019 Irrv Tr | Organization | Indirect Ownership Interest | NOT APPLICABLE | 06/27/2019 |
| Laura Cirese Tutera 2011 Irrevocable Trust | Organization | Indirect Ownership Interest | NOT APPLICABLE | 11/20/2013 |
| Tutera Investments, LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 12/31/2023 |
| Bloom, Randall | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/04/2004 |
| Bloom, Randall | Individual | ADP of the SNF | NOT APPLICABLE | 04/25/2017 |
| Brooks, Kiley | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2019 |
| Brooks, Kiley | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2019 |
| Hipskind, Timothy | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2025 |
| Hipskind, Timothy | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2025 |
| Thorson, Angela | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2025 |
| Thorson, Angela | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2025 |
| Ti-Coulterville, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/31/2017 |
| Tutera, Joseph | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/25/2017 |
| Tutera, Joseph | Individual | ADP of the SNF | NOT APPLICABLE | 04/25/2017 |
| Wagner, Alisa | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2025 |
| Wagner, Alisa | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "How many hours a day is a registered nurse physically in the building, including weekends?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Who oversees antibiotic use here, and how do you decide when an antibiotic is really needed?"
- "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 |
|---|---|---|---|---|---|
| Randolph County Care Center | 6.6 mi | Sparta, IL | ★☆☆☆☆ | 2/5 | |
| Pinckneyville Nursing & Rehab | 15.3 mi | Pinckneyville, IL | ★★★☆☆ | 4/5 | |
| Axiom Gardens of Nashville | 16.4 mi | Nashville, IL | ★☆☆☆☆ | 1/5 | abuseSFF |
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Facility data as of CMS processing date 2026-08-01. CCN 145993.