LA SALLE COUNTY NURSING HOME
Government - County
79 Beds
Independent
Data: November 2025
Trust Grade
55/100
#158 of 665 in IL
Photo by Dena Levy
Photo by Dena Levy
Photo by Denise Shepherd
1 / 6 photos
Last Inspection: August 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
La Salle County Nursing Home has received a Trust Grade of C, which means it is average compared to other facilities. It ranks #158 out of 665 nursing homes in Illinois, placing it in the top half, but #5 out of 9 in La Salle County indicates there are better local options available. The facility is showing improvement, having reduced issues from 11 in 2024 to just 1 in 2025. Staffing is a strong point, with a perfect score of 5/5 stars and a turnover rate of 41%, which is below the state average, suggesting that staff are experienced and familiar with residents. However, the facility has faced some serious concerns, including a resident experiencing significant weight loss without proper intervention and another resident sustaining a hip fracture due to inadequate fall precautions. Additionally, there were issues with food storage and cleanliness that could affect all residents, indicating some areas need attention despite the overall positive staffing situation.
- Trust Score
- C
- In Illinois
- #158/665
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ○ Average
- 41% turnover. Near Illinois's 48% average. Typical for the industry.
- Penalties ⚠ Watch
- $27,983 in fines. Higher than 87% of Illinois facilities, suggesting repeated compliance issues.
- Skilled Nurses ✓ Good
- Each resident gets 61 minutes of Registered Nurse (RN) attention daily — more than 97% of Illinois nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 24 deficiencies on record. Higher than average. Multiple issues found across inspections.
55/100
Top 23%
Needs review
11 → 1 violations
★★★★☆
4.0
Overall Rating
★★★★★
5.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 11 issues
2025: 1 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (41%)
7 points below Illinois average of 48%
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
Staff Turnover: 41%
Near Illinois avg (46%)
Typical for the industry
Federal Fines: $27,983
Below median ($33,413)
Moderate penalties - review what triggered them
The Ugly 24 deficiencies on record
2 actual harm
Feb 2025
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
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 ...
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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 Assistant/CNA) said she was working Wednesday 1/29/2025. V7 said residents were served a smaller amount of food that day. V7 said R4 and R5 were only served 1-2 packets of graham crackers that day.
On 2/10/2025 at 10:08AM and 1:10PM, V8 (CNA) said she worked on Wednesday 1/29/2025. V8 said residents received 1 packet of crackers that day. V8 said R1 was complaining of being hungry after breakfast. V8 said R6 received a couple of crackers not six that day.
On 2/10/2025 at 12:02PM, V1 (Administrator) she gets a test tray every day from the kitchen. V1 said she was only served two packages of crackers on that day (Wednesday 1/29/2025) on the test tray.
On 2/10/2025 at 11:16AM, V9 (Registered Dietician/RD) said if the menu says the residents should receive six graham crackers, then they should receive six. V9 said it throws off the amount of carbs the resident gets if they don't receive the right amount of graham crackers. V9 said the menu should be followed.
The facility provided Emergency Menu Guide for No Electricity, No Gas shows day 3 (1/29/2025) breakfast 4 ounces of juice, ¾ cup of cheerios, 6 crackers, 2 tablespoons of peanut butter, 1 ounce of jelly, and 8 ounces of milk.
Aug 2024
10 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
A resident was harmed · This affected 1 resident
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 sampl...
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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 significant weight loss of 10.2% in one month (7/3/24 to 8/6/24) and 12.9% loss in six months.
The Electronic Health Record for R33, does not document that V4 (Dietary Manager) or V17 (R33's Physician) was notified of R33's significant weight loss.
The current Physician Order Sheet for R33, documents R33 is on a regular diet with no other dietary orders and to ensure R33 was offered snack three times a day.
On 8/12/24 through 8/14/25, between 8:30 am through 3:00 pm, R33 paced the facility, circling one hallway to the next, and refused to rest frequently. On 8/13/24, 8/14/24, and 8/15/24, R33 was not seen in the dining room during mealtimes and was walking the hallways during those times. Meal trays were delivered to R33's room and R33 did not eat the meal provided.
On 8/14/24 at 9:11 am, V2 (Director of Nursing) stated, We all encourage (R33) to rest and take breaks and she will at times. Sometimes (R33) with say no and keep on walking. We have to encourage her frequently.
On 8/14/23 at 10:00 am, V10 (Certified Nursing Assistant/CNA), V11 (CNA), and V12 (CNA) stated R33 walks around the facility all day long. R33 used to be given finger foods and she would eat while walking but R33 won't eat now. R33 won't eat in the dining room most of the time and will say she is not hungry.
On 8/15/24 at 9:45 am, V15 (Restorative CNA) stated she does all the monthly weights for the facility. V15 stated the last weight she got for R33 was 120 something (pounds), so she reweighed R33 and that is when she got the weight of 132 (pounds) and put the weight in R33's medical record. I did notice (R33) had a weight loss. V15 stated R33 walks even more now, it is harder to get her to stay focused, and her attention span is shorter than it used to be.
On 8/15/24 at 12:58 pm, V2 stated she does all the monthly weight meetings and is unaware of R33 having any recent weight loss. V2 stated, No one has reported anything to me.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
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:
T...
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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, history of CVA (Cerebral Vascular Accident), on antidepressant, diuretics, anti-seizure, antihypertensive with an intervention of Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**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...
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**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 date 3/28/23, documents PASRR Level I Determination: No Level II Required - Situational symptoms; Mental Health Diagnoses - Anxiety Disorder, current.
R22's Minimum Data Set/MDS assessment, dated 6/20/23, documents 'Psychiatric/Mood Disorder: Diagnoses include: Psychotic disorder (other than schizophrenia) and Anxiety Disorder; Yes - Antipsychotics were received on a routine basis only.
On 8/13/24, at 2:25pm, V22 (Admissions Coordinator) stated, On admission I request a Level I or whatever they required .V9 (Social Service Director/SSD) coordinates with V6 (Minimum Data Set/MDS and Care plan Coordinator) regarding changes like behaviors or medications. V9 would get a Level II if needed. If she is not here, then I would intervene and do it.
On 8/14/24, at 11:55am, V6 (MDS/Care plan Coordinator) confirmed R22's Face Sheet includes a diagnosis of Unspecified Psychosis. V6 stated the following: (R22) came in with that diagnosis and was on Seroquel. I did not mark psychosis on (R22's) admission MDS because I did not have the psychotic diagnosis until 4/20/24 when we got verification from the doctor. V6 confirmed that R22 should have had another PASRR Level I Screening done when we saw that diagnosis.
On 8/15/24, at 8:37am, V9 (SSD) stated the following: I did not realize that (R22) had the psychotic disorder diagnosis. If I had known, I would have put in for another Level 1 Screening then they would have determined if a Level II was needed. V9 confirmed that R22 should have been referred for another Level I Screening.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
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 nebu...
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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 an Ipratropium Bromide & Albuterol nebulizer treatment to R5. V8 did not auscultate R5's lungs or take any vital signs before or after the treatment.
On 8/14/24 at 1:43pm, V8 (LPN) confirmed that V8 did not auscultate R5's lungs or take R5's vital signs before or after giving R5 a nebulizer treatment. V8 stated, I don't auscultate lungs or take vitals unless the doctor ordered it specifically or it is a prn (as needed) dose for someone having breathing issues. (R5) gets nebulizer treatments regularly. I don't do that for scheduled maintenance nebulizer treatments but would for prn.
On 8/14/24, at 2:30pm, V2 (Director of Nursing) confirmed that their policy states they are to auscultate lungs and take vital signs before and after a nebulizer treatment. V2 stated We will have to change our policy since that is not what we are doing for residents with scheduled nebulizer treatments.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
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 Re...
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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: (R53) has orders for duplicate therapy. Trazodone 100mg (milligrams) q hs (every bedtime) and Melatonin 5mg q hs. Recommendation: Please discontinue one agent. If dual therapy is to continue, it is recommended that a) the prescriber document an assessment of risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual; and b) the facility interdisciplinary team ensures ongoing monitoring for effectiveness and potential adverse consequences. Physician's Response: I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below. The Rationale is blank.
On 8/14/24, at 4:05pm, V2 (Director of Nursing) confirmed that V23 (R53's Nurse Practitioner) signed the Consultation Report but did not give a rationale and should have.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
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 i...
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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 of infection following the criteria for clinical infecting on the infection Report form as well as in the nurses' notes. 4.) Floor nurse shall update the physician with a change in condition. if infection criteria met, inform physician of antibiotic algorithm as well as any culture and sensitivity results, and the strict standards our antibiotic stewardship program follows. 5.) If orders are received for antibiotics, double check the algorithm and or sensitivity report before administrating. If a conflict is noted, update physician and request replacement.
R16's Physician Order Sheet, dated 8/14/2024, documents the following: Macrobid Oral Capsule 100 MG (milligram) (Nitrofurantoin Monohydric Macro Anti-bacterial) give one capsule by mouth one time a day every other day for UTI (urinary tract infection) prophylactic related to personal history of urinary tract infection. Order date 6/13/2024- (admission date). Start date 6/14/2024.
R16's Progress Notes, dated 7/24/2024, documents the following: (R16) remains on prophylactic antibiotics. No signs of adverse effect or complaints.
R16's Care Plan, dated 6/26/2024, documents the following: R16's urinary tract infection is related to chronic history of UTI. Intervention: Obtain and monitor lab/diagnostic work as ordered. Report results to V17 (R16's Physician) and follow-up as indicated.
On 8/14/2024 at 11:10 AM V2 (Director of Nurses) stated, R16 was admitted to us with this antibiotic in place. R16 is hospice, so we just left her on the Macrobid (antibiotic). No labs or urinalysis have been done for (R16) to indicate that (R16) has a UTI.
2. On 8/12/24 at 10:54 am, R51 stated she is on an antibiotic for a UTI (urinary tract infection) and has not had any problems with it. R51 stated Today is the last day.
The urine laboratory results for R51, dated 7/29/24, documents a urine culture was obtained for R51. This laboratory result does not document R51 with a current urinary tract infection. This form has a handwritten physician order to administer the Antibiotic Macrobid, even though the colony count for R51 was not indicating infection due to symptomatic.
The current Physician Orders for R51, document a Physician Order dated 8/5/24 for R51 to start Macrobid 100 mg (milligrams) bid (twice daily) for seven days for symptomatic urinary with no infection noted.
The Progress Notes for R51 documents the following: 8/5/24 Received new order for Macrobid despite no infection noted for symptomatic urinary issues and 8/6/24 Remains on Macrobid for urinary issues but has no active infection at this time, temperature 97.9 degrees.
On 8/15/24 at 8:40 am, V3 (Infection Control Preventionist) stated she believes that R51 had a urinary tract infection. V3 confirmed R51's urine culture did not indicate R51 with a urinary tract infection due to the colony count not being high enough but R51's Physician decided to treat her anyway.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
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 ...
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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 prevent or reduce behavioral symptoms and/or distress, types and the consequences of behaviors exhibited by the resident and interventions that may be indicated for a specific behavior type .5. Psychotropic medications to treat behaviors will be used appropriately to address specific underlying medical or psychiatric causes of behavioral symptoms .13. When Physician/Prescriber orders a psychotropic medication for a resident, facility should ensure that Physician/Prescriber has conducted a comprehensive assessment of the resident and has documented in the clinical record that the psychopharmacologic medication is necessary. 14. If Physician/Prescriber orders a psychotropic medication in the absence of a diagnosis Facility should ensure that the ordering Physician/Prescriber reviews the medication plan and considers a gradual dose reduction (GDR) of psychotropic medications for the purpose of finding the lowest effective dose unless a GDR is clinically contraindicated. 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.
1. On 8/12/24, at 12:32pm, R53 sat quietly in the Dining Room eating with assistance.
On 8/13/24, at 1:25pm, R53 sat quietly in the lounge area eating a cookie.
On 8/15/24, at 10:20am, R53 sat quietly in the Activity room smiling while watching the game being played.
R53's current Physician Order Sheet/POS documents diagnoses including but not limited to Unspecified Dementia without Behavior Disturbance, Restlessness and Agitation, and Insomnia; there are no diagnoses for Anxiety or Depression.
R53's Medication Administration Records/MARs for July and August 2024 includes orders for Lorazepam Oral Tablet 0.5 mg (milligrams) (Lorazepam) *Controlled Drug* Give 1 tablet by mouth every 8 hours as needed for anxiety for 14 Days and Trazadone HCl (Hydrochloride) Oral Tablet 100mg Give 100 mg by mouth at bedtime for insomnia related to Primary Insomnia.
R53's July MAR documents R53 received Trazadone every evening and Lorazepam on 7/1, 7/3, and 7/31/24. There is no documentation of any behavior on this MAR or in R53's Nursing Progress Notes.
R53's August MAR documents R53 received Trazadone every evening and Lorazepam on 8/5, 8/10, and 8/11/24. There is no documentation of any behavior on this MAR or in R53's Nursing Progress Notes.
R53's Behavior Summary Reports for 7/1/24 - 8/15/24, do not include specific targeted behaviors.
On 8/14/24, at 12:05pm, V6 (Minimum Data Set/Care Plan Coordinator) stated that R53's indication for use of Ativan is anxiety and the indication for use of Trazadone is insomnia. V6 stated that the diagnosis for R53's Ativan is restlessness and agitation. V6 confirmed that restlessness and agitation are symptoms and was unable to locate a diagnosis of Anxiety from R53's clinical record. V6 stated that Trazadone is an Anti-depressant, but the diagnosis for Trazadone is insomnia. V6 was unable to locate a diagnosis of Depression from R53's clinical record.
On 8/15/24, at 10:15am V2 (Director of Nursing) stated there are no individualized targeted behaviors documented for (R53) or (R49). V2 confirmed that they go by the generic behaviors that the CNAs (Certified Nursing Assistants) track. V2 also confirmed that R53's list of diagnoses do not include Anxiety or Depression and should.
On 8/15/24, at 1:47pm, V19-V21 (CNAs) stated that R53 gets antsy at times, but does not have any aggressive or harmful behaviors.
2. The current Physician Orders for R49 document R49 is currently receiving the following psychotropic medications: Duloxetine 60 mg/milligrams daily, Mirtazapine 7.5 mg in the evening and Ativan 0.5 mg three times daily.
On 8/12/24 at 9:45 am, 8/13/24 at 9:38 am, 12:03 pm, and on 8/14/24 at 8:40 am and 12:00 pm, R49 was alert and oriented, up in a wheelchair in his room, in the dining room, or lying in bed with eyes closed and without behaviors.
On 8/14/24 at 9:20 am, V2 (Director of Nursing) stated R49 came to the facility as a Hospice patient, is alert and oriented with periods of confusion and is currently receiving psychotropic medications for Anxiety and Depression. V2 stated R49 has not had any behaviors related to his Depression or Anxiety but generally does well. V2 stated, We have not had any behaviors from him.
On 8/14/24 at 10:00 am, 10:07 am, and 10:12 am, V10, V11, and V12 CNAs stated R49 is alert and oriented with periods of confusion, able to make needs known and has not had any behaviors, other than refusing cares at times and will reproach at later time with no problems.
On 8/15/24 at 10:15 am, V2 stated the staff just chart any behaviors that R49 might have in the progress notes and on the Behavior Tracking sheets. V2 confirmed there are no specific targeted behaviors for R49.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
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...
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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 days after opened. V4 opened the drink refrigerator and there were two containers of thickened water, one apple and one cranberry thickened liquid containers open and undated. V4 stated that the containers of thickened liquids are to be dated when opened and kept for only seven days. A container of whole liquid eggs was dated as opened on 7/1/24. V4 verified that the eggs are only kept for seven days after opened. The two basket deep fryer baskets were covered in a dark brown greasy substance. The oil in the deep fryer was dark brown with burnt foods and crumbs on the bottom and on the shelf of the fryer. V4 stated that the deep fryer oil is to be changed weekly. V4 also stated that the debris is to be filtered out of the oil every night. V4 stated that is does not appear that it was done last night. The convection oven had a spilled brownish liquid on the floor. V4 stated that the chicken leaked over this morning the oven will be cleaned today.
On 8/13/24 at 1:30pm, the convection oven had a dark brown dry crusty area on the floor. V4 verified that the oven was not cleaned yesterday (8/12/24).
On 8/15/24 at 9:30am, V5 (District Dietary Manager) verified that all opened foods are to be covered and dated when opened. V5 stated that opened items are only kept for seven days.
The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 8/12/24, documents 59 residents residing in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected most or all residents
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...
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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 Assistant/HR (Human Resources) Coordinator.
The facility's Quality Assessment and Assurance Committee Meeting, dated 4/18/24, documents Absent for this meeting: (V16 Previous Administrator).
The facility's Quarterly Quality Assurance Meeting Attendance Record, dated 4/18/24, does not include a signature by V16.
On 8/15/24, at 9:29am, V2 (Director of Nursing) confirmed that (V16) the previous Administrator was not at the April 18, 2024, meeting.
The facility's Long-Term Care Facility Application for Medicare and Medicaid, dated 8/12/24, documents a census of 59 residents residing in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected most or all residents
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 ...
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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 appropriateness of prophylaxis. F.) Physician compliance tracking and education. Procedure 4.) Infection Prevention Program Coordinator has the key expertise and data to inform strategies to improve antibiotic use. The Infection Preventionist tracks antibiotics, monitors adherence to evidence-based published criteria, reviews antibiotic resistance patterns in the facility. In coordinating using education and training, dedicated time, and resources to collect and analyze surveillance data, this will be used to support the antibiotic stewardship program.
The facility's Monthly Infection Control Log dated May 1st through May 31st 2024, documents only the following information: Residents name, body site, and antibiotic with start date. The Infection Control Log for May is blank for the following pertinent information: Date of onset of infection, a culture when applicable, organism, antibiotic resistant, and classification of the infection, type of antibiotic, how long the antibiotic is for and symptoms to support the use of the antibiotic.
The facility's Monthly Infection Control Log dated June 1st through June 31st 2024, documents only the following information: Residents name, body site, the antibiotic with start date and what the resident is being treated for. June's Infection Control Log does not document the following pertinent information: Date of the onset of the infection, a culture when applicable, antibiotic resistant, the classification of the infection, the organism that is being treated, any symptoms to support the use of the antibiotic, and stop date for the antibiotic.
On 8/14/2024 at 11:32 AM V3 (Infection Preventionist), stated, I have not started the Infection Control Log for July or August yet. Typically, it should be started at the beginning of each month to accurately track, monitor infections or any trends, and to ensure that the resident is being treated appropriately for the infection. The logs are not complete.
The facility's Long-Term Care Facility Application for Medicare and Medicaid form dated 8/12/2024, documents 59 residents currently reside within the facility.
Mar 2024
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
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 ...
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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 (Licensed Practical Nurse/LPN) kept R1 by her side, due to R1 repeatedly trying to walk. R1 was given a stuffed animal to hold. V4 documented that she came out of a room after giving a medication and heard R1 say AH! R1 was rubbing her left knee. V4 documented that R1's knees were checked for injuries, but none were noted. R1 was asked if she could move her legs, which she did. R1 was assisted up to her wheelchair. R1 progress notes document that R1 was rubbing above her knees. V6 (R1's Primary Care Physician) gave orders for hip and knee x-rays.
R1's Progress Notes, dated 2/13/24 at 12:45am, documents that R1 was crying out with facial grimacing and grabbing her left leg and hip area. R1 was sent to the emergency room for suspected hip fracture. At 4:14am, V3 (Registered Nurse) documented that R1 was being admitted to the hospital for a left hip fracture.
V9's (Certified Nursing Assistant) signed Witness Interview Form, dated 2/12/24, documents that Resident (R1) frequently stands, self-transfers, walks around unsupervised. This form documents that R1 was one on one with the nurse while passing medications.
On 3/13/24 at 10:30am, V7 (Registered Nurse/Minimum Data Set Nurse) stated that R1's base line care plan did not have fall interventions put into place. V7 verified that R1 should have had a completed care plan at the time of her fall.
On 3/13/24 at 2:20pm, V1 (Administrator) stated that R1 had a history of falls prior to admission to the facility. V1 stated that the facility does not have the staff to do one on one care.
On 3/13/24 at 2:50pm, V4 (LPN) stated that R1 was anxious and kept trying to stand up. V4 stated that the staff could not get their jobs done, so she took R1 with her during medication pass. V4 stated that she entered a room to give medicine then heard a Ah. V4 stated she went to check on R1 and she was on the floor. V4 stated that R1 was rubbing her knees but did not show signs or symptoms of pain. V4 verified that R1 had adverse behaviors often. V4 verified that R1 was out of sight for only a minute and fell. V4 stated that R1 did not get out of bed after returning from the hospital.
The facility's Care Plans policy, reviewed 03/13/24, documents that the resident care plan is initiated at the time of admission. This form documents that the care plan will include the following information but not limited: needs, concerns or problems identified during initial assessment of the resident.
The facility's Falls and Incident Reporting policy, modified 10/31/23, documents that a Fall risk Assessment 2.0 Form is to be completed as soon as possible and practicable, within 24-48 hours as practicable, when a resident has sustained a fall. This form also documents that the resident's care plan is reviewed and revised as indicated. Approaches will be implemented for ongoing evaluation of interventions will be done on a resident individualized basis.
Nov 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**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 (R...
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**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 wheeled up (in her wheelchair) to R2 and was cursing at R2. Summary indicates R2 then grabbed R1's arm and tapped R1 three times. Summary indicates R2 stated that R1 had hit her first.
R2's current care plan indicates R2 had a recent incident (10/13/23) of hitting another resident on the arm and R2 can become verbal with other confused residents and engage in yelling or arguments.
R2's care plan was not revised to include any specific interventions to prevent further resident to resident altercations.
2) Current Physician Order Summary Report indicates R4 was admitted to the facility on [DATE] with diagnoses of Dementia without Behavioral Disturbance, Other Psychotic Disorder and Anxiety Disorder.
Incident Investigation Summary (undated) indicates on 10/19/23 R1 wheeled up (in her wheelchair) to R4 and pushed/slapped at R4's shoulder.
R4's current care plan indicates R4 wanders aimlessly and significantly intrudes on the privacy (of others) and/or activities.
R4's care plan was not revised to include incident with R1 and did not include interventions to prevent further resident to resident altercation.
On 11/2/23 at 2:30pm V3 (Social Service Director) stated she is responsible for behavior care planning and R2 and R4's care plans should have been either updated or developed after each incident.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**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,...
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**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 Behavioral Disturbance, Cognitive Communication Deficit and Anxiety Disorder.
Incident Investigation Summary (undated) indicates on 10/13/23 R1 wheeled up (in her wheelchair) to R2 and was cursing at R2. Summary indicates R2 then grabbed R1's arm and tapped R1 three times.
2.) Incident Investigation Summary (undated) indicates on 10/16/23 R1 struck out at R3 because R1 thought R3 was in her room (R1 was in R3's room). Summary indicates a Stop Sign was applied to the doorway of R3's room to prevent other residents from entering.
R3's care plan did not include focus area to include R3 as recipient of R1's behaviors or interventions to prevent future incidents.
3.) Incident Investigation Summary (undated) also indicates on 10/19/23 R1 wheeled up to R4 and slapped at/pushed R4's shoulder.
4.) Incident Investigation Summary (undated) indicates on 10/14/23 R1 slapped at R5 while sitting behind R5 in the dining room making light contact. Summary indicates R1 was moved immediately.
R5's care plan did not include focus area to include R5 as recipient of R1's behaviors or interventions to prevent future incidents.
On 11/2/23 at 2:30pm V3, SSD (Social Service Director) stated she is responsible for behavior care planning and R1, R2, R3, R4 and R5's care plans should have been either updated or developed after each incident.
5.) Email dated 6/23/23 at 12:05pm (from facility to Ombudsman) indicates R6 was having safety issues with her electric wheelchair. Email indicates R6 pinned a staff member against a soda machine, got the wheelchair footrests stuck under her bed - requiring assistance to get unstuck and (on 6/23/23) rammed her feet under her bed causing a gash on top of her foot requiring stitches. Email indicates R6 was very upset when told she must use a manual wheelchair until an electric wheelchair evaluation could be done. Email indicates the facility is also concerned about the safety of other residents.
Nurse Note dated 8/10/23 at 10:15am indicates that when given a new manual wheelchair to use, R6 stated her plan was to move to another facility where she would be able to use her motorized chair. Note indicates at that time, R6 was advised that once insurance is submitted for a custom chair - her electric chair would no longer be covered. Note indicates R6 was adamant that she did not want a custom manual chair and wanted to keep her electric chair covered.
Nurse Note dated 8/11/23 at 10:30am indicates staff told R6 the reason she is not allowed to use her electric wheelchair is because R6 cannot safely operate the chair. Note indicates R6 became agitated and yelling that it was the facility's fault.
Nurse Note dated 9/12/23 at 2:00pm indicates R6 wanted to know when she would be getting her electric wheelchair returned. Note indicates R6 stated that her independence is being taken away.
Nurse Note dated 10/4/23 at 10:30am indicates R6 upset and tearful over electric wheelchair - upset that she is not able to use motorized wheelchair in the facility.
Nurse Note dated 10/5/23 at 10:06pm indicates R6 became very tearful in the dining room and was upset that she is not able to use her motorized chair. Note indicates R6 feels she is not able to do the things she would like to do because her chair is not comfortable. Note indicates R6 was worried about her warranty being voided on her motorized chair.
Email dated 10/10/23 at 10:59am (Ombudsman to facility) indicates R6 is asking about her electric wheelchair Insisting it be returned to her.
On 11/2/23 at 9:45am V1 (Administrator) stated (R6) is just not safe in the electric wheelchair. She is still upset, obsessed with losing her chair. Not rational when staff try to explain the reasons, she can't use it in the facility.
On 11/2/23 at 1pm R6 was in her room in a large reclining wheelchair. At that time R6 stated I have to wait now for staff to take me wherever I want to go. I have no life now. I'm actively looking for a group home I can go to. I'm not happy here.
R6's current care plan does not address R6's unsafe behavior or incidence as related to R6's electric wheelchair and does not address the resulting psycho-social impact on R6's wellbeing.
On 11/2/23 at 3:00pm V1 (Administrator) stated she was unaware a care plan had not been developed to address the issues with R6's electric wheelchair or R6's difficulty adjusting to its loss. V1 stated V3 should have added these areas to R6's care plan.
Aug 2023
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
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:
Facilit...
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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.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
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 Liv...
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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 all residents who are SCHEDULED to receive a shower. All skin Audit sheets are to be submitted to the mailbox of the Wound Nurse/Infection Preventionist.
On 8-15-23, at 10:58am, R49 was sleeping on a couch in the lounge area across from the nurses' station with messy, greasy hair.
On 8-17-23, at 3:20pm, R49 was sleeping on a couch in the same lounge area. R49's hair appears greasy. R49 looks unkempt.
On 8-18-23, at 8:35am, R49 was awake and in pajamas out in the facility's front lobby area lounging in a chair. R49 appears unkempt with greasy, messy hair.
On 8-18-23, at 8:50am, while R11 was ambulating the hallways, R11 complained of R49 being dirty and sleeping on the facility's couches and chairs.
On 8-18-23, at 9:28am, R49 was sleeping on a couch in the lounge area across from the nurses' station. R49 looks unkempt with greasy, messy hair.
R49's current Physician Order Sheet/POS includes the diagnoses of Unspecified Dementia, Urinary incontinence, and Cognitive communication deficit.
R49's MDS (Minimum Data Set) assessment, dated 7-18-23, documents R49 requires physical assist with one person for bathing, is frequently incontinent of bladder, and occasionally incontinent of bowel.
R49's current Care plan includes The resident is resistive to care: has not wanted to get out of bed or changed when incontinent. (R49) can become verbal with other confused residents and engage in yelling or arguments. Interventions include: If resident resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again.
The facility's A Wing Shower Days list document R49 is to get a shower on day shift on Tuesday and Friday with hair washed.
On 8-17-23, at 3:00pm V11 (MDS/Care plan Coordinator) was unable to produce any Shower sheets (Skin Audit sheets) for July or August 2023 for R49. V11 stated they should be doing them and agreed that without them there is no documentation of R49 receiving shower.
On 8-18-23, at 9:07am, V2 (Director of Nursing/DON) stated the following: (R49) can be difficult with cares. Her motivation is when she is going out with her male friend. (R49) doesn't get physical, but loud and agitated. The staff are to back off then re-approach. If a resident is refusing, the girls (staff) should mark shower sheets and turn into the nurse. V2 confirmed there haven't been shower sheets for R49 in quite a while. They (staff) should be documenting in notes or on the shower sheets, so we know (R49's) refusing. If a resident refuses a shower, then they should get a full bed bath. V2 continued to state that R49's Progress notes say that on August 18(R49) got cleaned up, but it doesn't say (R49) was showered. At this time, V2 confirmed the last documented shower for R49 was on 7-19-23 according to progress notes.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
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...
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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 in the morning and nothing has been touched including the CCD snacks.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
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, cle...
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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 cross-contamination; including handwashing and/or changing gloves after performing personal care, or when performing tasks that provide the opportunity for cross-contamination to occur (i.e., facility equipment).
1.) On 8/17/23 at 10:37am, V7 (Registered Nurse/RN) went into R40's room to perform cares. V7 grabbed R256's overbed table to perform cares for R40. After cares for R40, V7 did not cleanse R256's overbed table. V7 then placed R256's overbed table back on R256's side of the room and left the room.
On 8/17/23 at 10:37am, V7 (RN) stated I usually use a cleanser with 70 percent alcohol on the bedside table after I do cares for (R40). I did not have the cleanser on my cart, so I did not clean (R256's) table after I used it for (R40).
2.) On 8/17/23 at 9:21, R45 was in bed in her room.
On 8/17/23 at 10:10am, V7 (RN) was performing wound cares with R45 when R45 became incontinent of stool. V7 grabbed R45's incontinence brief and pushed R45's incontinence brief full of stool together and down under R45's buttocks, and without changing V7's gloves, V7 used the same gloves to put on R45's new dressing. V7 then snapped R45's stool filled brief back on over R45's new dressing.
On 8/17/23 at 11:55am, V7 RN stated, I should have changed (R45) when she was incontinent of stool and changed my gloves before doing the dressing change.
3.) On 8/17/23 at 1:15pm, R29 was lying in bed. At that same time, V10 (Certified Nurse Assistant/CNA) performed personal cares for R29. After performing personal cares for R29, V10 did not wash her hands or use waterless hand antiseptic between glove changes. V10 put on new gloves and put on R29's new brief. V10 did not wash her hands or use waterless hand antiseptic after changing her gloves and grabbed R29's two blankets and put on R29.
On 8/17/23 at 1:20pm, V10 stated I should have washed my hands between glove changes.
4) Facility Policy/Glucometer Decontamination dated 2012 documents: The glucometer will be decontaminated with the facility approved wipes following use on each resident. After performing the glucometer testing, the nurse shall perform hand hygiene, don gloves, and use the disinfectant wipe to clean all external parts of the glucometer. A specific amount of contact time is not required for cleaning. A second wipe shall be used to disinfect the glucometer, allowing the meter to remain wet for the contact time required by the disinfectant label. The clean glucometer will be placed on a paper towel.
On 8/17/23 at 11:30am V8 (RN) performed a blood glucose test for R11 which required extracting a drop of blood from R11's finger. After completing the blood glucose test, V8 administered insulin to R11, returned to the medication cart and put the glucometer back into the top drawer of the medication cart and closed the drawer.
On 8/17/23 at 11:35am V8 stated I forgot to clean the glucometer, I usually clean after I used it. V8 then proceeded to remove the glucometer from the drawer, removed bleach wipes from the bottom drawer of the medication cart and wiped the glucometer for approximately 20 seconds and placed the glucometer on top of the medication cart. V8 stated she preferred to use bleach wipes, but product can change and All of them have different contact and cleaning times.
Bleach wipe instruction for use indicate to clean/wipe surfaces of non-porous materials and to keep wet for three minutes.
5) Facility Policy/General Dose Preparation and Medication Administration dated/revised 1/1/13 documents: Facility staff should not touch the medication when opening a bottle or unit dose package.
On 8/17/23 at 11:50am V5 (RN) dispensed one tablet of Reglan (antiemetic) 5mg (milligrams) into a medication cup. As V5 pushed the tablet through the foil seal, the tablet split into two halves. While preparing to administer the Reglan tablet to R42, the medication cup tipped over and both halves of the tablet spilled out onto the top of the medication cart. V5 then picked up both halves of the tablet with her bare hands, placed the halves back into their medication cup and administered the medication to R42.
On 8/17/23 at 1:45pm V5 acknowledged she should have used gloves to pick up the Reglan from the cart before administering to R42.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
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 (R1...
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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 vaccination for influenza (flu) and pneumatically vaccinations were presented for R10, R16, R40, R45 and R50. At that time V9 stated that she only verbally received consent for the flu vaccinations given to R10, R16 and R40 in October 2022. V9 stated that R45's flu vaccination was historical and R50 had no record of flu immunization although was admitted in February of 2023. V9 stated that there is no written consent or education on benefits or side effects in the medical records.
The handwritten list of dates of vaccinations for R10, R16, R40, R45 and R50 indicates I called the families. They gave verbal consent, but it's not charted.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected most or all residents
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 facilit...
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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 possible.
Resident Census and Condition Report indicates 59 total residents in the facility on 8/15/23.
Refrigerator/Freezer Temperature Logs dated July and August 2023 document:
Standard: 41 degrees (F) or colder - Refrigerator
July 2023 Log - Temperatures documented only for July 19, 20 and 26 - 31. July 19 and 20 were documented at 30 degrees (F) and July 26 to July 30 were documented at 32 degrees (F).
August 2023 Log - Temperatures only documented for August 1, 4, 6 - 8 and 11-16.
On 8/17/23 at 11:35am V5 (Registered Nurse) stated night shift checks and records the temperature of the medication refrigerator. V5 confirmed there is only one medication room/medication refrigerator in the facility which receives medications for all facility residents.
2.) Facility Policy/Storage and Expiration Dating of Medications, Biologicals dated/revised 8/7/23 documents: Controlled Substances Storage: Controlled Substances stored in the refrigerator must be in a separate container and double locked.
On 8/17/23 at 11:30am facility medication storage room contained one refrigerator with a latch that was unlocked with a padlock sitting next to the latch directly on top of the refrigerator.
The medication room refrigerator contained unopened controlled medications for the following residents:
Liquid Morphine (opiate/narcotic) - R27, R29, R40, R45
Liquid Lorazepam (benzodiazepine) - R45
V5 (Registered Nurse) stated I really don't know, but I'm assuming since there are narcotics in the refrigerator it should be locked. The narcotics in the medication cart need to be double locked.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected most or all residents
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 meal...
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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 potatoes, and spinach instead. We have new workers in the kitchen, and they messed up the weeks on our menu.
On 8/16/23 at 11:15am All nine residents (R5, R8, R11, R12, R23, R28, R42, R46, R50) attending a group meeting at that time stated that meals were not following the menus posted and all nine agreed the meal served not matching the meal posted had been going on for a while and believed it was due to constantly changing dietary staff.
Food Committee Meeting notes dated June 15, 2023 indicate Residents complained when meal tickets are made with changes, they don't always get what they have chosen.
Food Committee Meeting notes dated July 20, 2023 indicate Residents are upset with menus being changed. They would like to know when menu is being changed.
Jul 2022
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**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, pre...
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**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 includes the following Focus Areas: (R4) is at high risk for impairment to skin integrity related to immobility. Also included are the following Interventions: Keep skin clean and dry.
R4's Braden Scale for Predicting Pressure Ulcer Risk, dated 7/13/21 documents that R4 is High Risk for skin breakdown.
R4's Hospital After Visit Summary, dated 8/11/21 documents, (R1) was seen today due to a leg injury. Imaging Tests performed: Femur, Pelvis, Bilateral tibia and Fibula. Instructions: (Bilateral) Knee Immobilizers. Wound care around knee immobilizers daily. Diagnosis: Closed Fracture of Right Distal Femur, Closed Fracture of the Left Proximal Tibia.
R4's electronic Medical Record documents, 8/11/2021 23:26 (11:26 P.M.) Note Text: (R4) returned at this time from (local hospital) by ambulance. report rec'd (received) from ER (Emergency Room) nurse they had x-rays done on the pelvic area along with both lower extremities, right femur fx (fracture) noted along with a fx (fracture) to the left tibia as well. New orders for bilateral knee immobilizers to be worn at all times.
R4's electronic Medical Record documents, 8/24/2021 22:54 (11:54 P.M. Skin/Wound Note: During care time, staff called in this Nurse, drainage noted from right ankle, 3x2 cm (Centimeter) wound, yellow center, red edges. Cleansed and foam dressing applied.
R4's facility Weekly Wound Observation Tool, dated 8/26/21 documents, 3 CM X 2 CM X .7 pressure wound to right medial malleolus with yellow slough present to wound bed.
R4's Physician Progress Note, dated 8/26/21 documents, (R4) grimaced when right leg was stretched to check on pressure wound on right medial malleolus area. Plan: Consult Wound Nurse. Ok to continue (enzymatic debriding agent). Check for any decubitus ulcers/sores on coccyx and other pressure areas.
R4's electronic Medical Record documents, 9/10/2021 13:59 (1:59 P.M.) Skin/Wound Note: Unstageable wound noted to right medial malleolus measuring 3.5 x 2.3 cm. Surrounding tissue is red and blanchable. Wound bed is 50% slough and 40% necrosis and 10% granulation around edges. Large amount of serous drainage noted. Pt grimaced when foot was lifted. No odor or warmth noted. New SDTI (suspected deep tissue injury) noted superior to unstageable wound measuring 3.2x1x utd (undetermined tissue depth) cm, dark purple non blanchable area. Surrounding tissue is dry and intact, no odor, redness warmth or drainage noted.
New unstageable wound noted to left medial malleolus measuring 4x2.5 cm with 4x2x utd cm patch of SDTI just superior to open area. Wound is 100% slough covered. Redness noted, mod (Moderate) amount of serous drainage with no odor. Pt (R4) grimaced with dressing change, nurse notified. Called PCP (Primary Care Physician) office to notify her that immobilizers have been removed since they are likely the cause of the wounds. Waiting on call back.
R4's electronic Medical Record documents, 7/14/2022 12:28 (P.M.) Skin/Wound Note: Inferior lower lt (Left) leg, 5.5 (CM) x 1 x 0.1 Area is 75% red, pink/red with granulation, 25% yellow slough, with a sc. (Scant) amt. (Amount) of sanguineous drainage. Cleanse wound with NS (Normal Saline), apply a thin layer of (Antimicrobialroto (Non-adherent Wound Dressing) and cover with foam & ABD (Abdominal Wound Dressing pad), wrap with gauze. Change q (Every) 3 days and PRN (As needed). Peri wound is inflamed/erythematic, dry scaly skin noted around the area, lotion applied to dry skin around wound. Will cont. (Continue) to monitor.
On 7/18/22 at 11:25 A.M., R4 was seated in a high back reclining wheelchair at bedside, sleeping. A blue foam boot was present to R4's left lower leg. A gauze bandage was wrapped around R4's lower left leg.
On 7/19/22 at 10:20 A.M., V3/Wound Nurse stated, I remember when (R4) returned from the hospital (last year). She had fractures in both legs, and they ordered full leg braces for both legs. I'm not sure if they got removed or not, but a couple of weeks later, they found deep tissue injuries underneath of them. They should have been removed everyday with cares and the skin underneath of them checked.
On 7/19/22 at 12:35 P.M., V2 (Director of Nursing) stated, (R4) has always had problems with swelling in her legs, especially her left leg. Back in October (R4) had a fall from her bed and had a CT scan, which was negative and a number of lacerations. A few days later the staff noticed some swelling in (R4's) right knee and we called the doctor and requested an X-ray. The doctor had us send (R4) back to the ER and they x-rayed both legs and found fractures in both legs. They put on long leg braces that went from (R4's) upper leg to (R4's) ankles. (R4) was supposed to have them taken off for daily hygiene. (R4) only wore them for about two weeks. We were worried about (R4's) skin underneath and a few weeks later staff found a deep tissue wound on (R4's) right malleolus where the brace rubbed against it. A few days later, we found a pressure wound on (R4's) left calf, from pressure from that brace.
On 7/21/22 at 10:08 A.M., V3 (Wound Nurse) prepared to provide wound care for R4. After removing and disposing of a soiled bandage, V3 cleansed R4's lower leg pressure wound. A 1.2 CM X 1 CM open wound with a 3 CM necrotic area superior to the open wound was present. The wound had tan drainage with an odor. The surrounding tissue area was beefy red with thick, yellow scales present. The top of R4's left foot was swollen to approximately twice the size. V3 cleansed the wound with normal Saline, applied an anti-microbial ointment to a foam pad, placed the pad on the wound and covered R4's lower leg with gauze.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
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 thr...
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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 in the urine colonized. (date of order 07/14/22).
On 07/20/22 at 12:47 PM, a sign was posted on the door to R20's room that indicated Contact Isolation Precautions. V6 and V7 (Certified Nursing Assistants) applied personal protective equipment obtained from a supply bin in the hallway and then entered R20's room. V6 and V7 transferred R20 from her wheelchair into bed with a full mechanical lift to provide incontinence care. V6 and V7 removed R20's soiled incontinence brief, and V7 provided positioning assistance while V6 cleansed R20's perineal area with a soapy washcloth. V6 wiped R20's perineum in a back to front motion, starting near R20's rectal area moving toward her labia. V6 then rinsed the visibly soiled washcloth in a basin of soap and water and handed the same washcloth to V7. V6 rolled R20 to her right side and provided positioning assistance while V7 cleansed R20's rectal area. V6 and V7 then applied a clean incontinence brief to R20, repositioned R20 in bed on her right side with several pillows, and covered R20 with a sheet. R20 stated, It hurts when I have to pee. I need to get this checked out. Once incontinence care was completed, V6 picked up the bed remote and lowered R20's bed, while V7 placed R20's call light within her reach. V6 and V7 were wearing the same pair of gloves throughout this time.
On 07/20/22 at 01:05 PM, V6 confirmed that she wiped R20's perineum in a back to front motion while providing incontinence care, starting near R20's rectal area and wiping towards R20's labia. V6 also confirmed that neither she nor V7 changed gloves until R20's incontinence care was completed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
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 d...
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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, End Stage Renal Disease, Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 5 Chronic Kidney Disease, Anemia in Chronic Kidney Disease, Dependence on Renal Dialysis. This same form documents the following physician orders: Regular, No Added Salt diet with a 946 CC (Cubic Centimeters) Fluid Restriction. No bananas or oranges or orange juice; and Hemodialysis 3 days a week on Tuesday, Thursday, and Saturday.
R31's current Care Plan, dated 4/3/18 includes the following Focus area: (R31) has (a) potential nutritional problem related to No Added Salt, Renal Diet, Fluid Restrictions, on Dialysis. And the following Interventions: Provide and serve diet as ordered. Monitor intake and record each meal. Also included is the following Focus area: (R31) needs dialysis related to Renal Failure and the following Interventions: Diet as ordered. Provide sack lunch from the (facility) kitchen for her to bring with to dialysis on Tuesday, Thursday and Saturday.
On 07/18/22 at 11:47 A.M., R31 was seated on the side of the bed with a bedside table positioned in front of her. A dialysis shunt was visible to R31's right forearm. At that time, R31 stated, I go to dialysis on Tuesdays, Thursdays and Saturdays at 5:00 A.M. My brother takes me. When questioned on what she receives for breakfast and when she receives it, V31 stated, I don't get any breakfast before I go to dialysis. No one is in the kitchen at that time. I don't get a sack lunch to take with me, either. Sometimes my brother stops at gets me a breakfast sandwich. On the days I have dialysis, I have the girls (staff) bring my lunch tray to my room, but I don't usually eat it. I'm too tired on dialysis days.
On 7/18/22 1:43 P.M., V4 (Dialysis Clinical Manager) stated, I am the Clinical Manager at the dialysis center. (R31) comes early morning, three days a week. Her (dialysis) treatment starts at 5:30 A.M. Since the pandemic, we don't allow clients that are receiving dialysis to eat when they are in the dialysis den. We don't want them to take their masks down. Now, (R31) can bring a sack lunch with her and eat on the way here, while she's waiting to get in the (dialysis) chair or on her way home. She is a diabetic and also takes a phosphate binder (medication) that is given before dialysis but must be taken with food due to its side effects. It's very important that she eats breakfast before her (dialysis) treatment.
On 7/18/22 at 1:26 P.M., V5 (Dietary Manager) stated, The day shift kitchen staff comes in at 5:30 (A.M.). I think (R31) leaves the building at 5:00 A.M. We used to provide her breakfast or give her a sack lunch before she left for dialysis, but we don't anymore. (R31) doesn't ask for anything, anymore.
On 7/18/22 at 1:31 P.M., V2 (Director of Nurses) confirmed that R31 had dialysis on Tuesday, Thursday, and Saturday. When questioned what (R31) receives for breakfast on dialysis treatment days, V2 stated, I think (R31) takes a sack lunch with her. I don't know what's in it.
On 7/18/22 at 3:15 P.M., V1 (Administrator) stated that she is not able to provide a current signed and dated dialysis agreement with the local dialysis facility.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 41% turnover. Below Illinois's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 2 harm violation(s), $27,983 in fines, Payment denial on record. Review inspection reports carefully.
- • 24 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
- • $27,983 in fines. Higher than 94% of Illinois facilities, suggesting repeated compliance issues.
- • Grade C (55/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 55/100. Visit in person and ask pointed questions.
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About This Facility
What is La Salle County's CMS Rating?
CMS assigns LA SALLE COUNTY NURSING HOME an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Illinois, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is La Salle County Staffed?
CMS rates LA SALLE COUNTY NURSING HOME's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 41%, compared to the Illinois average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at La Salle County?
State health inspectors documented 24 deficiencies at LA SALLE COUNTY NURSING HOME during 2022 to 2025. These included: 2 that caused actual resident harm and 22 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates La Salle County?
LA SALLE COUNTY NURSING HOME is owned by a government entity. Government-operated facilities are typically run by state, county, or municipal agencies. The facility operates independently rather than as part of a larger chain. With 79 certified beds and approximately 59 residents (about 75% occupancy), it is a smaller facility located in OTTAWA, Illinois.
How Does La Salle County Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, LA SALLE COUNTY NURSING HOME's overall rating (4 stars) is above the state average of 2.5, staff turnover (41%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting La Salle County?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is La Salle County Safe?
Based on CMS inspection data, LA SALLE COUNTY NURSING HOME has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Illinois. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at La Salle County Stick Around?
LA SALLE COUNTY NURSING HOME has a staff turnover rate of 41%, which is about average for Illinois nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was La Salle County Ever Fined?
LA SALLE COUNTY NURSING HOME has been fined $27,983 across 1 penalty action. This is below the Illinois average of $33,359. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is La Salle County on Any Federal Watch List?
LA SALLE COUNTY NURSING HOME is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.