Cycle 1
Health 2025-03-27 · Fire 2025-03-27
11 health deficiencies
Top issue: Infection Control (3 deficiencies)
21 fire-safety deficiencies
Top issue: Emergency Preparedness (11 deficiencies)
Lena, IL
Lena Living Center
4-star overall rating with 4-star inspections with $90,772 in total fines with 11 recent health deficiencies with 21 fire-safety deficiencies in the latest cycle
1010 South Logan Street, Lena, IL
(815) 369-4561
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
92
Certified beds
Average residents
53
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2007-07-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.80
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.30
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.60
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.70
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.10
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.02
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.75
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.92
CMS adjusted RN staffing hours
Adjusted total hours
4.26
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,871
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.33
Composite VBP score used to determine payment impact.
Payment multiplier
0.9953
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.87
Baseline 18.91% · Performance 19.17% · Measure score 4.87 · Achievement 4.87 · Improvement 0
Healthcare-associated infections
7.12
Baseline 5.86% · Performance 5.71% · Measure score 7.12 · Achievement 7.12 · Improvement 1.31
Total nurse turnover
3.19
Baseline 89.74% · Performance 65.79% · Measure score 3.19 · Achievement 0 · Improvement 3.19
Adjusted total nurse staffing
1.75
Baseline 3.21 hours · Performance 3.57 hours · Measure score 1.75 · Achievement 1.75 · Improvement 0.92
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.41% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 73 · Observed rate 12.33% · Lower 95% interval 7.13% |
| Discharge to community | 48.35% |
50.57%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 66 · Observed rate 43.94% · Lower 95% interval 37.6% |
| Medicare spending per beneficiary | 1.18 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 39 · Denominator 39 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 39 |
| Discharge self-care score | 57.14% |
53.69%
3.5 pts better
|
Numerator 20 · Denominator 35 |
| Discharge mobility score | 54.29% |
50.94%
3.4 pts better
|
Numerator 19 · Denominator 35 |
| Pressure ulcers or injuries, new or worsened | 7.69% |
2.29%
5.4 pts worse
|
Numerator 3 · Denominator 39 · Adjusted rate 10% |
| Healthcare-associated infections requiring hospitalization | 5.71% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 47 · Observed rate 0% · Lower 95% interval 2.73% |
| Staff COVID-19 vaccination coverage | 24.64% |
8.2%
16.4 pts better
|
Numerator 17 · Denominator 69 |
| Staff flu vaccination coverage | 6.8% |
42%
35.2 pts worse
|
Numerator 7 · Denominator 103 |
| Discharge function score | 51.43% |
56.45%
5 pts worse
|
Numerator 18 · Denominator 35 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 20.83% |
25.2%
4.4 pts worse
|
Numerator 5 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.0
0.3 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.2 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.0 |
2.3
0.7 pts worse
|
1.8
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.7 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 70.8% |
89.6%
18.8 pts worse
|
93.4%
22.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 78.7% · Q2 71.1% · Q3 66.0% · Q4 67.4% · 4Q avg 70.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 62.0% |
91.6%
29.6 pts worse
|
95.5%
33.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 62.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.3% |
3.3%
1 pts worse
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 4.4% · Q3 2.1% · Q4 4.3% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 12.4% |
50.3%
37.9 pts better
|
11.4%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 15.0% · Q3 13.3% · Q4 9.1% · 4Q avg 12.4% |
| Percentage of long-stay residents who lose too much weight | 12.0% |
6.5%
5.5 pts worse
|
5.4%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 16.2% · Q3 10.3% · Q4 15.4% · 4Q avg 12.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.1% |
18.5%
11.6 pts worse
|
19.6%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 32.4% · Q3 30.0% · Q4 32.5% · 4Q avg 30.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 32.2% |
22.8%
9.4 pts worse
|
16.7%
15.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.0% · Q2 28.6% · Q3 33.3% · Q4 36.4% · 4Q avg 32.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.6% |
17.2%
0.6 pts better
|
16.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 37.8% · Q3 3.2% · Q4 0.0% · 4Q avg 16.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.8% |
15.0%
2.2 pts better
|
14.9%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 21.6% · Q3 5.0% · Q4 0.0% · 4Q avg 12.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.0% |
1.1%
0.9 pts worse
|
1.0%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.4% · Q3 3.2% · Q4 1.4% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
1.7%
0.6 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.8% |
21.3%
5.5 pts better
|
19.8%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 30.7% · Q3 6.2% · Q4 8.3% · 4Q avg 15.8% |
| Percentage of long-stay residents with pressure ulcers | 9.2% |
5.2%
4 pts worse
|
5.1%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 7.9% · Q3 12.9% · Q4 9.5% · 4Q avg 9.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 11.4% |
68.8%
57.4 pts worse
|
81.7%
70.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 10.0% · Q3 6.7% · Q4 9.4% · 4Q avg 11.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.9% |
14.0%
2.1 pts better
|
12.0%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.9% · Observed 11.8% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.3%
2.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 13.7% |
63.0%
49.3 pts worse
|
79.7%
66 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 13.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.2% |
26.2%
1 pts worse
|
23.9%
3.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.2% · Observed 32.4% · Expected 28.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-12 · Fire 2024-04-12
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
12 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Cycle 3
Health 2023-05-25 · Fire 2023-05-25
14 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-27
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2025-05-09
F · Potential for more than minimal harm
2025-03-27
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-05-09
F · Potential for more than minimal harm
2025-03-27
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2025-05-09
F · Potential for more than minimal harm
2025-03-27
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2025-05-09
F · Potential for more than minimal harm
2025-03-27
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2025-05-09
F · Potential for more than minimal harm
2025-03-27
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-05-09
F · Potential for more than minimal harm
2025-03-27
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2025-05-09
F · Potential for more than minimal harm
2025-03-27
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2025-05-09
F · Potential for more than minimal harm
2025-03-27
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-05-09
F · Potential for more than minimal harm
2025-03-27
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-05-09
F · Potential for more than minimal harm
2025-03-27
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-05-09
F · Potential for more than minimal harm
2025-03-27
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-05-09
F · Potential for more than minimal harm
2025-03-27
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-05-09
F · Potential for more than minimal harm
2025-03-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-09
F · Potential for more than minimal harm
2025-03-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-09
F · Potential for more than minimal harm
2025-03-27
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-05-09
F · Potential for more than minimal harm
2025-03-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-03-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-03-27
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-03-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-09
C · Minimal harm
2025-03-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-09
F · Potential for more than minimal harm
2024-04-12
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-05-30
F · Potential for more than minimal harm
2024-04-12
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2024-05-30
F · Potential for more than minimal harm
2024-04-12
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-05-24
F · Potential for more than minimal harm
2024-04-12
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-05-30
F · Potential for more than minimal harm
2024-04-12
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-05-24
F · Potential for more than minimal harm
2024-04-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-06
F · Potential for more than minimal harm
2024-04-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-28
F · Potential for more than minimal harm
2024-04-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-30
F · Potential for more than minimal harm
2024-04-12
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2024-05-24
E · Potential for more than minimal harm
2024-04-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-24
E · Potential for more than minimal harm
2024-04-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-05-24
D · Potential for more than minimal harm
2024-04-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-05-24
F · Potential for more than minimal harm
2023-05-25
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-07-05
F · Potential for more than minimal harm
2023-05-25
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-07-12
F · Potential for more than minimal harm
2023-05-25
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-07-12
F · Potential for more than minimal harm
2023-05-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-30
F · Potential for more than minimal harm
2023-05-25
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-07-12
F · Potential for more than minimal harm
2023-05-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-12
F · Potential for more than minimal harm
2023-05-25
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-07-12
F · Potential for more than minimal harm
2023-05-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-30
F · Potential for more than minimal harm
2023-05-25
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-06-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-18
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-11-20
F · Potential for more than minimal harm
2025-03-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-27
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-27
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-27
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-27
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-27
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-27
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-02-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-28
D · Potential for more than minimal harm
2024-09-30
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-08-27
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-09-19
G · Actual harm
2024-08-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-15
F · Potential for more than minimal harm
2024-04-12
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-05-03
E · Potential for more than minimal harm
2024-04-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-03
E · Potential for more than minimal harm
2024-04-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-08
D · Potential for more than minimal harm
2024-04-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-04-12
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-04-12
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-05-08
D · Potential for more than minimal harm
2024-04-12
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-04-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-08
D · Potential for more than minimal harm
2024-01-26
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-03-09
G · Actual harm
2023-05-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-06-08
F · Potential for more than minimal harm
2023-05-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-06-08
E · Potential for more than minimal harm
2023-05-25
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-06-08
D · Potential for more than minimal harm
2023-05-25
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-06-08
D · Potential for more than minimal harm
2023-05-25
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-06-08
D · Potential for more than minimal harm
2023-05-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-08
D · Potential for more than minimal harm
2023-05-25
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2023-06-08
D · Potential for more than minimal harm
2023-05-25
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-07-27
D · Potential for more than minimal harm
2023-05-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-08
D · Potential for more than minimal harm
2023-05-25
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-06-08
E · Potential for more than minimal harm
2023-03-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-10
D · Potential for more than minimal harm
2023-03-22
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-04-10
D · Potential for more than minimal harm
2023-03-22
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-04-10
Penalties and ownership
What sits behind the stars
$90,772
2023-05-25
Fine
Fine · fine $90,772
Fine
$0
2023-05-25
Payment Denial
Payment Denial · denial start 2023-06-20 · 37 days
37 day denial
Ownership
Koenig, Suzanne
5% Or Greater Direct Ownership Interest · Individual
Koenig, Suzanne
Operational/Managerial Control · Individual
Mcdonald, Dustin
Operational/Managerial Control · Individual
Sak Management Services LLC
Operational/Managerial Control · Organization
Schleich, Jeffrey
Operational/Managerial Control · Individual
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