La Salle County Nursing Home
1380 North 27th Road, Ottawa, IL 61350 · Government - County · 79 certified beds · (815) 433-0476 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (35% vs 45% nationally) — better care continuity
- it has 2 actual-harm citations
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $146,063 in federal fines (most recent 2025-08-06)
- its facility-reported quality-measure score sits well above its independent inspection score
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 18.4% | 13.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.6% | 6.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.1% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 4.7% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 1.3% | 54.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 5.5% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 12.0% | 14.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 16.7% | 18.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.3% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.2% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 26.7% | 20.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 2.9% | 21.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 88.5% | 63.1% | 79.4% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.69 | 2.02 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.35 | 2.22 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.21 therapist hours per resident per day in 2026Q1 — more than 26% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 20% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.24 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 79 beds and averages 67.9 residents a day — about 86% occupied, or roughly 11 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.54 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.83 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.35 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.05 hrs/resident/day on weekends vs 3.74 on weekdays — 19% thinner on weekends. RN hours go from 0.96 to 0.52 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 35% is below the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
24 citations, most serious first. The 12 most serious are shown; the remaining 12 are one tap away and print in full.
- Actual harm · G2024-08-15 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to identify a severe weight loss and put interventions in place for one (R33) of one resident reviewed for nutrition in the sample of 27. This failure resulted in R33 having a continued severe weight loss of 10.2% in one month and 12.9% loss in six months. Findings include: The facility's Resident Weight policy, dated 7/1/18, documents Any significant weight discrepancy from the previous weight is to be investigated at that time to rule out errors in weighing the resident (scale errors, incorrect procedure.) The nurse will report significant weight gains or losses to the physician and to the dietary department. (Significant weight gains or losses are defined as 5% in one month, 7.5% in 3 months, or 10% in 6 months. The Monthly Weight Summary for R33, documents the following weights: 8/15/24 at 128.0 pounds; 8/6/24 at 132.0 pounds; 7/3/24 at 147.0 pounds; 6/4/24 at 144.4 pounds; 5/2/24 at 148.0 pounds; 4/8/24 at 146.0 pounds; 3/12/24 at 145.0 pounds; and 2/12/24 at 147.0 pounds. This weight record documents a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2024-03-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to implement fall interventions for a resident at risk for falls for one of three residents (R1) reviewed for falls in a sample of three. This failure resulted in R1 experiencing an unwitnessed fall, subsequently sustaining a left hip fracture requiring surgical repair. Findings include: R1's admission Fall Risk Assessment, dated 2/2/24 documents that R1 is at risk for falls. R1's Baseline Care Plan, dated 2/2/24, documents that R1 requires one-person physical assist for locomotion on the unit. This form documents that R1 is cognitively impaired. R1's baseline care plan does not have fall or safety interventions in place. R1's Restorative/Rehabilitation Evaluation, dated 2/2/24, documents that R1 requires extensive assist of one person for transfers. R1's Progress Notes, dated 2/11/24 at 6:45am, documents that R1 was awake at 4:15am. R1 was assisted to bed, but got out of bed. R1 was taken to the bathroom and fluids were offered, will continue to monitor. R1's Progress Notes, dated 2/12/24, documents that at 8:30pm, V4…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-02-10 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and record review the facility failed to follow their emergency menu. This applies to 4 of 6 (R1, R4, R5, R6) in the sample of 6. The findings include: On 2/10/2025 at 9:26AM and 10:15AM, R1 said on Wednesday 1/29/2025 the kitchen wasn't working. R1 said he was served graham crackers and peanut butter for breakfast. R1 said he received two packages of crackers for breakfast. R1 said he was still hungry, and breakfast didn't have enough food to fill him up. On 2/10/2025 at 10:44AM, R4 said he remembers Wednesday 1/29/2025 being served 2 packages (4 crackers) for breakfast that day. R4 said he doesn't recall being hungry after breakfast. On 2/10/2025 at 9:47AM, V5 (Kitchen Manager) said on Monday 1/27/2025 through Wednesday 1/29/2025 said the kitchen had electrical issues and the facility was on emergency meals for three days. V5 said the breakfast while on the emergency meal plan included graham crackers and the residents should have received six graham crackers or three packages of graham crackers each. On 2/10/2025 at 10:05AM and 1:02PM, V7 (Certified Nursing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-08-15 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to date opened food items, use items within the opened date timeframe, and failed to implement the cleaning schedule of equipment. This has the potential to affect all 59 residents residing in the facility. Findings include: The facility's Food Storage: Cold Foods, revised 04/2018, documents that all foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. The facility's Equipment policy, revised 09/2017, documents that all food service equipment will be clean, sanitary, and in proper working order. This form also documents that all food contact equipment will be cleaned and sanitized after every use. This form documents that all non-foods contact equipment will be clean and free of debris. On 8/12/24 at 9:00am there were four plastic containers of open, undated cereal on the counter. V4 (Dietary Manager) stated that the cereal is supposed to be dated when it is opened and put into the containers. V4 stated that it is only good for seven…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-08-15 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure all required staff attended the facility's Quality Assurance Meetings. This has the potential to affect all 59 residents residing in the facility. Findings include: The facility's policy Quality Assurance and Performance Improvement (QAPI) last modified 6-20-18, documents Procedures: 1) The facility will maintain, at all times including staff transitions, a Quality Assurance and Performance Improvement (QAPI) committee which will meet at least quarterly and more frequently according to the facility's needs. The committee will consist of at least the following: 1. The QAPI officer. 2. The Medical Director of this facility. 3. The Administrator of this facility. 4. The Director of Nursing. 5. The Restorative RN (Registered Nurse). 6. The Admissions Coordinator. 7. The Dietary Service Coordinator. 8. The Director of Social Services. 9. The Pharmaceutical Representative. 10. The Infection Control/Preventionist Coordinator. 11. Activities Coordinator. 12. MDS (Minimum Data Set) Coordinator. 13. Administrative…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-08-15 · tag F0881 — failed to use antibiotics responsibly — widespreadImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure that the Antibiotic Stewardship Program was complete, accurate and done monthly for residents who are receiving antibiotics or have any type of infection. This failure has the potential to affect all 59 residents residing in the facility. Findings Include: The facility policy, named Antibiotic Stewardship-Infection Control Program, no date, documents the following: It is the policy of the facility is to monitor and maintain an Antibiotic Stewardship Program that monitors the use of antibiotics and their order specifics to decrease the amount antibiotic resistant organisms following the procedure: A.) Utilize the antibiotic tracking form to monitor reason for antibiotics and; B.) Identify the use of antibiotics and the appropriateness of the situation. C.) Analyze if antibiotic meets the appropriate criteria for infection using the algorithm for treatment of specific infections if available. D.) Track whether the patient is colonized and/or if they are clinically infected. Only treat if warranted. E.) Monitor for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-15 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure resident call devices were in reach for one (R8) of 15 reviewed for call devices in a sample of 27. Findings include: The undated facility's Call Light, Use Of policy documents Procedure: 11. Be sure call lights are placed within resident reach at all times, never on the floor or bedside stand. On 8/12/24, at 10:05am, R8 sat in a recliner in her room. R8 stated that she uses the call light for help to get to the bathroom. I am on a water pill, so I go a lot. At this time R8's call device is on the floor beside her and out of R8's reach. On 8/12/24, at 10:10am, V18 (Unit Attendant), stated the following: As a Unit Attendant I answer call lights and also when in a room I check to make sure the residents have their call light. On 8/12/24, at 10:16am, V18 confirmed R8's call device was on the floor and stated, It must have fallen when she got up in the chair earlier and I didn't see it. R8's current Care Plan includes a focus of The resident is at moderate risk for falls related to incontinence, hemiplegia,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-15 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to perform a PASRR (Pre-admission Screening & Resident Review) rescreen after a severe mental illness diagnosis was added for one (R22) one resident reviewed for PASRRs in a sample of 27. Findings include: The facility's undated PASRR policy documents a Project Introductions including but not limited to PASRR. Level I screen identifies known/suspected PASRR conditions: MI (Mental Illness)/ID (Intellectual Disability)/RC (related condition). Level II assessment - individualized to determine presence of MI/ID/RC and needed services and supports. Determination & Needs - (NFs) Nursing Facility's must incorporate PASRR findings in the person's plan of care. Refer for Level II - Has/suspected PASRR condition; Requires a Level II. R22's Face Sheet documents R22 admitted to the facility on [DATE] and includes a diagnosis of Unspecified Psychosis not due to a Substance or known Physiological Condition with a revised date of 4/20/23. R22's PASARR Level I, review…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-15 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure a respiratory assessment was completed pre and post nebulizer treatment for one (R5) of one resident reviewed for nebulizer treatments in a sample of 27. Findings include: The facility's undated Nebulizer policy documents Purpose: 1. To administer bronchial medications and humidifying agents into the lungs. 2. To assist in loosening lung secretions .Procedure: 6. Note pre-treatment data such as pulse and breath sounds .14. Note post treatment data (pulse, breath sounds and any side effects) and record in the medical record. (If pulse is increased more than 20 beats per minute over baseline, notify Physician.). R5's current Physician Order Sheet/POS documents R5 has an order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) mg (milligrams)/3ml (millimeters) (Ipratropium-Albuterol) 1 vial inhale orally via nebulizer four times a day related to Chronic Obstructive Pulmonary Disease, Unspecified. On 8/14/24, from 9:45am - 10:00am, R5 sat in her room. V8 (Licensed Practical Nurse/LPN) administered…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-15 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a rationale was documented by the physician for a pharmacy recommendation for one (R53) of five residents reviewed for Medication Regimen Review in a sample of 27. Findings include: The facility's Psychotropic Medication Use policy, revised 10/24/22, documents Definition - Psychotropic drugs include but are not limited to antipsychotics, anti-anxiety, antidepressants, or sedative-hypnotics that affect brain activities associated with mental processes and behavior .14.1 Physician/Prescriber should document the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior. R53's Physician Order Sheet/POS includes orders for Trazadone HCl (Hydrochloride) 100mg (milligrams) by mouth at bedtime for insomnia related to Primary Insomnia and Melatonin 5 mg by mouth at bedtime for insomnia related to Primary Insomnia. R53's Consultation Report, dated on 7/24/24 and signed by V23 (R53's Nurse Practitioner), documents Comment:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-15 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the facility failed to document the rational for the continued use of an antibiotic for two of three residents (R16 and R51) reviewed for unnecessary medications in a sample of 27. Findings Include: The facility's Antibiotic Stewardship-Infection Control policy, undated, documents the following: Procedure of Core Elements, D.) Action-Implementing at least one policy or practice to improve antibiotic use this facility will implement a stricter policy (s) on antibiotic order specifics including, but not limited to identifying clinical situations in which inappropriate antibiotics are used such as asymptomatic urinary tract infections, treating a colonized asymptomatic resident, prophylaxis, and guidelines for treating infections. The key element involved is control over antibiotic use which will reduce the threat of antibiotic resistance. The goal is to add one or two activities to start the program and over time as the program evolves implement more strategies to improve antibiotic use. Procedure 3.) The nurse shall document any signs and symptoms…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-15 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure proper diagnoses and targeted behaviors were in place for psychotropic medications for two residents (R53 and R49) of three residents reviewed for psychotropic medications in a sample of 27. Findings include: The facility's Psychotropic Medication Use policy, revised 10/24/22, documents Definition - Psychotropic drugs include but are not limited to antipsychotics, anti-anxiety, antidepressants, or sedative-hypnotics that affect brain activities associated with mental processes and behavior. Procedure - 1. Psychotropic medication is prescribed for a diagnosed condition and not being used for convenience or discipline .2.1 The facility should not use psychotropic medications to address behaviors without first determining if there is a medical, physical, functional, psychological, social or environmental cause of the resident's behaviors .2.1.3 Staff should become familiar with the cultural, medical, and psychological information about the resident to identify potential environmental and other triggers to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 12 citations
- Potential for harm · E2023-11-03 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop behavior care plans for four residents (R1, R3, R5, R6) of six residents reviewed for care plans. Findings include: Social Service Director Job Description, Essential Duties and Responsibilities dated 6/5/17 documents: Complete MDS (Minimum Data Set) assessments (Cognitive, Mood, Behavior, Hearing, Vision, Speech, and Discharge) and identify problems, concerns, goals, and interventions through developing and updating the Plan of Care according to Federal and State Regulations. 1.) Current Physician Order Summary Report indicates R1 was admitted to the facility on [DATE] with diagnoses of Dementia with Agitation, Alzheimer's Disease and Anxiety Disorder. R1's care plan did not include a developed focus area to address R1's multiple altercations with other residents or interventions to prevent further incidence. Current Physician Order Summary Report indicates R2 was admitted to the facility on [DATE] with diagnoses of Dementia with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-03 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to revise the comprehensive care plan for two residents (R2, R4) of six residents reviewed for resident-to-resident altercations. Findings include: Social Service Director Job Description, Essential Duties and Responsibilities dated 6/5/17 documents: Complete MDS (Minimum Data Set) assessments (Cognitive, Mood, Behavior, Hearing, Vision, Speech, and Discharge) and identify problems, concerns, goals, and interventions through developing and updating the Plan of Care according to Federal and State Regulations. Current Physician Order Summary Report indicates R1 was admitted to the facility on [DATE] with diagnoses of Dementia with Agitation, Alzheimer's Disease and Anxiety Disorder. Current Physician Order Summary Report indicates R2 was admitted to the facility on [DATE] with diagnoses of Dementia with Behavioral Disturbance, Cognitive Communication Deficit and Anxiety Disorder. Incident Investigation Summary (undated) indicates on 10/13/23 R1…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-08-18 · tag F0761 — failed to label and store drugs safely — widespreadEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to monitor refrigerated medication storage temperatures. This failure has the potential to affect all 59 residents in the facility. The facility also failed to ensure refrigerated controlled medications were double locked for four residents (R27, R29, R40, R45) during review for medication storage. Findings include: 1.) Facility Policy/Storage and Expiration Dating of medications and Biologicals dated/revised 8/7/23 documents: Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopoeia guidelines for temperature ranges. Refrigeration: 36 degrees Fahrenheit (F) to 46 degrees (F). Facility should monitor the temperature of medication storage areas at least once a day. Facility Policy/Refrigerator Cleaning dated 7/23 documents: Midnight Licensed staff monitors the temperatures of all refrigerators on the nursing unit nightly and documents on the form provided. Report temperatures over 40 degrees (F) to maintenance as soon as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-08-18 · tag F0803 — failed to meet residents' dietary needs — widespreadEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to provide meals according to the menu. This failure has the potential to affect all 59 residents in the facility who receive meals from the kitchen. Findings include: Facility Policy/Menus dated/revised 2017 documents: Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal. Resident Census and Condition Report indicates 59 total residents in the facility on 8/15/23. On 8/18/23 at 12:45pm V1 (Administrator) stated that all 59 residents in the facility receive meals from the kitchen. Facility Week at a Glance Menu, dated 8/8/23, documents that the scheduled Lunch Meal for 8/15/23 at 12:00 pm was Marinated Chicken Thighs, Sugar Snap Peas, Oven [NAME] potatoes, Dinner Roll and Chocolate Chip cookies. On 8/15/23, at 12:30pm, V4 (Dietary Manager) stated, Our menu is wrong. We prepared the wrong week's food on our Week at a Glance. The meal today should have been chicken thighs, peas, and potatoes, but my staff prepared ham, sweet…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-18 · tag F0809 — failed to serve meals on a reasonable schedule — patternEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to provide/offer bedtime snacks to nine residents (R5, R8, R11, R12, R23, R28, R42, R46, R50) of nine residents who attended a group meeting in the sample of 27. Findings include: Facility Policy/Snacks dated/revised 9/2017 documents: Bedtime snacks will be provided for all residents. Nursing services is responsible for delivering the individual snacks to the identified residents and for offering evening snacks to all other residents. On 8/16/23 at 11:10 am, all nine residents attending a group meeting at that time stated that bedtime snacks were offered sporadically. We might get them, or we might not. Food Committee Meeting notes dated June 15, 2023 indicate Residents reported that the snacks aren't available or being passed out. On 8/16/23 at 2:53pm V4 (Dietary Manager) stated All CCD (diabetic) snacks are labeled. The bucket containing snacks is on the snack cart which is left at the nurse's station. CNAs (Certified Nurse Assistants) are supposed to go around and offer snacks at night. Sometimes the snack cart comes back…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-18 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to administer medications without touching with bare hands, cleanse a glucometer, perform handwashing between glove changes, cleanse a bedside table to prevent cross contamination, and change gloves with cares for five (R11, R29, R40, R42, R45) out of 24 residents reviewed for infection control in a sample of 27. Findings include: Facility Infection Control Glove Technique, dated 3/14, documents Change gloves between tasks and procedures on the same resident after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident, and wash hands immediately to avoid transfer of microorganisms to other resident or environments. Remove gloves, dispose of gloves in the regular trash, and wash hands or Facility Infection Control program policy and procedures, undated, documents Preventing the spread of infection procedures must be followed to prevent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-18 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to provide consents for influenza vaccinations and provide documentation of vaccination education/potential side effects for five residents (R10, R16, R40, R45, R50) of five residents reviewed for immunizations in the sample of 27. Findings include: Facility Policy/Infection Control Resident Immunizations and Vaccinations dated 7/31/17 documents: The resident's medical record shall include documentation that indicates, at a minimum, the following: That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization and that the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. On 8/17/23 at 11:00 am a request was made to V7 (Registered Nurse/RN) and V9 (RN/Infection Preventionist) for influenza and pneumococcal vaccination documentation including consents for five residents (R10, R16, R40, R45, R50). On 8/17/23 at 12:00pm a handwritten list of dates of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-18 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, and record review, the facility failed to have a bedside table for one (R49) of 24 residents reviewed for room furnishings in a sample of 27. Findings include: Facility Resident Room Furnishings Policy, reviewed 6/23, documents Each resident shall have a sufficient number of tables that can be either rolled over the resident's bed or that can be placed next to the bed to serve every resident. On 8/15, 8/16, and 8/17/23, R40 did not have a bedside table in her room. On 8/17/23 at 10:37am V7 (Registered Nurse) was unable to find R40's bedside table. At that same time, V7 stated I don't know where (R40's) bedside table went, and she should have one. Everyone has to have one for use.
- Potential for harm · D2023-08-18 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure residents received scheduled showers for one resident (R49) of two residents reviewed for ADLs/Activities of Daily Living in a sample of 27. Findings include: The facility's Bathing and Showering, ADL's policy, and procedure, modified 8-16-23, documents Policies: 2. Each resident shall be scheduled for a shower twice a week and as is necessary to maintain personal hygiene, with showers being scheduled on every shift. Shower times may be changed on resident request and according to resident needs. Should the resident refuse hygiene cares by becoming combative, resistant, or other difficulties in cares, these refusals shall be documented in the resident's clinical record either in (name of software) or in the nursing record. And 12. Record skin observations on Skin Audit sheet. If a resident refuses a shower, then the Skin Audit sheet must be filed out indicating that the resident has refused the shower, including whom the shower was to be performed and by whom. A skin Audit sheet must be performed on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-21 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to prevent the development of bilateral, unstageable, pressure wounds to the right malleolus and left calf area for one of three residents (R4), reviewed for pressure wounds, in a sample of 31. The findings include: The (undated) facility policy, Pressure Ulcer Prevention and Treatment Interventions Guidelines directs staff, Daily Skin Hygiene and Inspection: Wash with mild soap, rinse and dry thoroughly. Moisturize skin with lotion to keep skin soft and pliable. Inspect the skin daily with cares for any issues. Inspect the skin under devices daily (splints, casts, immobilizers). R4's facility admission Record documents that R4 was admitted to the facility on [DATE] with the following diagnoses: Secondary Malignant Neoplasm of Brain, Hemiplegia and Hemiparesis Following Cerebrovascular Disease, Fracture of Right Femur, Fracture of Upper End of Left Tibia, Fracture of the Shaft of the Left Fibula. R4's current Care Plan, dated 9/12/2017…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-21 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to perform perineal care utilizing a front to back technique and failed to change gloves during incontinence care for one of three residents (R20) reviewed for urinary tract infection in the sample of 31. Findings include: The facility's Incontinence Care policy (dated 2008) documents the following: Wash the resident's perineal area from front to back with soap and water or incontinence preparation or disposable wipes. The facility's Infection Control Standard Precautions- Gloves policy (dated 2008) documents the following: Sterile gloves and examination gloves are removed: Before touching uncontaminated surfaces or other areas of the same resident's body that may be uncontaminated. R20's current medical record documents R20's diagnoses to include Urinary Tract Infection; Extended Spectrum Beta Lactamase (ESBL) Resistance; Candidiasis of Vulva and Vagina; Chronic Kidney Disease; and Overactive Bladder. R20's current Physician's Order Sheet documents the following order: On contact isolation r/t (related to) ESBL…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-21 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure a current dialysis agreement was in place and failed to ensure a dialysis resident received a morning meal, prior to dialysis, for one of one resident (R31) reviewed for dialysis in the sample of 31. Findings Include: The facility policy, Policy and Procedure for Dialysis, dated 2008 directs staff, To provide quality care and treatment services to the resident who requires dialysis. The SNF (Skilled Nursing Facility) will have an agreement, in writing, with a dialysis provider. General Communication and Coordination of Care. The (facility) dietary staff, the Dietary Director and Consultant RD (Registered Dietician) participate with other disciplinary team members to visit and observe resident's food and fluid intake and preferences. R31's current Minimum Data Set Assessment, dated 7/7/21 documents R31's cognitive status (Section C) as 15:15, cognitively intact. R31's current Physician Order Sheet, dated July 2022 includes the following diagnoses: Diabetes Mellitus with Diabetic Neuropathic Arthropathy,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$146,063 in federal fines across 2 penalties. 2 Medicare payment denials on record.
- $118,080 — penalty dated 2025-08-06
- $27,983 — penalty dated 2024-08-15
- Medicare payment denial — starting 2025-09-04 for 27 days
- Medicare payment denial — starting 2024-09-14 for 9 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| MEJIA, ELIANA | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 12/01/2025 |
| REYNOLDS, BRITTANY | Individual | INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER | — | since 07/24/2024 |
| LASALLE COUNTY BOARD OFFICE | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2007 |
CMS files one row per role, so the 8 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 146116. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-08-15, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.