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Deficiency Records for La Salle County Nursing Home
A list of the most recent deficiencies for La Salle County Nursing Home. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for La Salle County Nursing Home. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-08-15 | 2024-09-23 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-08-14 | 2024-09-21 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-08-14 | 2024-09-12 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2024-08-14 | 2024-09-12 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-08-14 | 2024-09-12 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-08-14 | 2024-09-12 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-08-14 | 2024-09-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-08-14 | 2024-09-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-08-14 | 2024-09-12 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2024-08-14 | 2024-09-11 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-08-15 | 2024-09-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-08-15 | 2024-09-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-08-15 | 2024-09-09 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-08-15 | 2024-09-09 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-08-15 | 2024-09-09 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-08-15 | 2024-09-09 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-08-15 | 2024-09-09 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-08-15 | 2024-09-09 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-08-15 | 2024-09-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-13 | 2024-04-03 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-03 | 2023-11-17 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-11-03 | 2023-11-17 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-08-18 | 2023-09-06 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-08-18 | 2023-08-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-18 | 2023-08-29 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-08-18 | 2023-08-29 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-08-18 | 2023-08-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-18 | 2023-08-29 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-08-18 | 2023-08-29 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-08-08 | 2023-08-25 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-08-08 | 2023-08-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-08 | 2023-08-25 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2023-08-08 | 2023-08-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-05 | 2023-07-27 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-24 | 2023-07-05 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-12 | 2022-10-20 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-07-21 | 2022-08-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-07-21 | 2022-08-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-21 | 2022-08-03 | N |
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