Fair Oaks Rehab & Healthcare
1515 Blackhawk Boulevard, South Beloit, IL 61080 · Winnebago County · 78 certified beds · avg 59 residents/day · certified since Oct 1, 1991
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 · Mar 10, 2026 · F-0600 · triggered by a complaint
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.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
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: Mar 11, 2026 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Feb 11, 2025 · F-0678 · triggered by a complaint
The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes.
Why it matters: In a cardiac or breathing emergency, failure to start CPR promptly can be the difference between life and death.
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: Feb 3, 2025 (Past Non-Compliance)
▲ Actual harm, one-off · Apr 6, 2026 · 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: Apr 13, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 11, 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: Feb 27, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (36)
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 6, 2026 | ▲ 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 |
| Mar 10, 2026 | ▲ J · Immediate jeopardy, 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 |
| Mar 10, 2026 | 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. · from a complaint |
| Dec 12, 2025 | D · Potential for harm, one-off | 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. · from a complaint |
| Sep 10, 2025 | E · Potential for harm, repeated | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Sep 10, 2025 | E · Potential for harm, repeated | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. |
| Sep 10, 2025 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Sep 10, 2025 | 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. |
| Sep 10, 2025 | 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. |
| Sep 10, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Sep 10, 2025 | 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. |
| Sep 10, 2025 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Sep 10, 2025 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Sep 10, 2025 | 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. |
| Jun 9, 2025 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Feb 11, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes. · from a complaint |
| Feb 11, 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 |
| Nov 12, 2024 | 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 |
| Oct 28, 2024 | D · Potential for harm, one-off | 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. · from a complaint |
| Oct 28, 2024 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · from a complaint |
| Sep 24, 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 17, 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 17, 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. |
| Jul 17, 2024 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Jul 17, 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 17, 2024 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Mar 20, 2024 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Nov 9, 2023 | D · Potential for 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. · from a complaint |
| Aug 31, 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. |
| Aug 31, 2023 | D · Potential for harm, one-off | 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. |
| Aug 31, 2023 | D · Potential for 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. |
| Aug 31, 2023 | 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. |
| Aug 31, 2023 | D · Potential for 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. |
| Aug 31, 2023 | 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. |
| Aug 31, 2023 | 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. |
| Aug 31, 2023 | D · Potential for harm, one-off | 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. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (5 → 10).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 9 | 0 | F |
| 2024 | 10 | 0 | E |
| 2025 | 14 | 2 | J ▲ |
| 2026 | 3 | 2 | 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)
3 fines totaling $71,124, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Mar 10, 2026 | Fine | $48,590 |
| Mar 10, 2026 | Payment Denial | 13 days from Mar 31, 2026 |
| Feb 11, 2025 | Fine | $8,161 |
| Feb 11, 2025 | Fine | $14,373 |
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) | 2.60 | 2.99 | 3.95 | bottom 45% in Illinois; bottom 5% in the U.S. |
| Registered Nurse hours | 0.56 | 0.63 | 0.69 | top 41% in Illinois; bottom 47% in the U.S. |
| Weekend total nurse staffing | 2.28 | 2.67 | 3.50 | bottom 41% in Illinois; bottom 5% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.47 | 0.56 | 0.48 | top 48% in Illinois; top 37% in the U.S. |
| Total nursing staff turnover (%) | 61.3 | 44.5 | 45.8 | bottom 13% in Illinois; bottom 15% in the U.S. |
| RN turnover (%) | 73.7 | 41.8 | 42.9 | bottom 7% in Illinois; bottom 9% 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 3.43, RN 0.74, weekend 3.01. 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 - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| JCT Investments, LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 05/12/2010 |
| Joseph Charles Tutera 2013 Family Irrevociable Trust Agreement | Organization | Indirect Ownership Interest | NOT APPLICABLE | 12/28/2021 |
| Marian Olander Tutera 2020 MRTL Tr | Organization | Indirect Ownership Interest | NOT APPLICABLE | 12/28/2021 |
| Tutera Investments, LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 12/28/2021 |
| Tutera, Joseph | Individual | Indirect Ownership Interest | NOT APPLICABLE | 12/28/2021 |
| Tutera, Marian | Individual | Indirect Ownership Interest | NOT APPLICABLE | 12/28/2021 |
| Bloom, Randall | Individual | Corporate Officer | NOT APPLICABLE | 12/28/2021 |
| Bloom, Randall | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/28/2021 |
| Bloom, Randall | Individual | ADP of the SNF | NOT APPLICABLE | 12/28/2021 |
| Brooks, Kiley | Individual | Corporate Officer | NOT APPLICABLE | 12/28/2021 |
| Brooks, Kiley | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/28/2021 |
| Brooks, Kiley | Individual | ADP of the SNF | NOT APPLICABLE | 12/28/2021 |
| Flanagan, Michael | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 04/12/2025 |
| Gillihan, Sherry | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2025 |
| Gillihan, Sherry | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2025 |
| Nika, Vasil | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2025 |
| Nika, Vasil | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2025 |
| Ti-South Beloit, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2019 |
| Tutera, Joseph | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/28/2021 |
| Tutera, Joseph | Individual | ADP of the SNF | NOT APPLICABLE | 12/28/2021 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "Are staff on every shift trained and certified in CPR, and how do they know each resident's resuscitation wishes?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
- "How do you handle residents who need modified food textures, and how do you make those meals appetizing?"
- "If my family member is able to manage their own medications, would you allow it, and how is that decided?"
- "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 |
|---|---|---|---|---|---|
| Autumn Lake Healthcare at Beloit | 3.8 mi | Beloit, WI | ★★★☆☆ | 3/5 | |
| Beloit Health and Rehabilitation Center | 5.0 mi | Beloit, WI | ★★☆☆☆ | 2/5 | |
| Alden Meadow Park HCC | 10.8 mi | Clinton, WI | ★★★☆☆ | 3/5 | |
| River Bluff Nursing Home | 10.9 mi | Rockford, IL | ★★☆☆☆ | 2/5 | |
| Avira Health Pavilion | 11.2 mi | Loves Park, IL | ★★★★☆ | 4/5 | |
| Willows Health Center | 11.3 mi | Rockford, IL | ★★★☆☆ | 3/5 | |
| Rock River Health Care | 11.4 mi | Rockford, IL | ★★★☆☆ | 3/5 | |
| Alpine Fireside Health Center | 11.5 mi | Rockford, IL | ★★★☆☆ | 3/5 | |
| Fairhaven Christian Ret Center | 11.7 mi | Rockford, IL | ★★★☆☆ | 3/5 | |
| Cedar Crest Health Center | 12.2 mi | Janesville, WI | ★★★★★ | 5/5 | |
| Mercyhealth Javon Bea Hospital -SNF | 12.8 mi | Rockford, IL | ★★★★☆ | 5/5 | |
| Amberwood Care Centre | 12.8 mi | Rockford, IL | ★★★☆☆ | 4/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 145702.