Cycle 1
Health 2025-02-14 · Fire 2025-02-14
12 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
11 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Las Vegas, NV
Royal Springs Healthcare And Rehab
2-star overall rating with 2-star inspections with $40,359 in total fines with 12 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
8501 Del Webb Blvd, Las Vegas, NV
(702) 804-3000
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
225
Certified beds
Average residents
215
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Il & Joan Lee
Operator or chain grouping
Approved since
1999-11-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
4 facilities
Chain averages 3 overall / 3 health / 4 staffing / 3 quality stars
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
0.82
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.66
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
3.25
All reported nurse hours · state 4.34 · national 3.89
Licensed hours
1.59
RN + LPN hours · state 1.97 · national 1.54
Weekend hours
2.83
Weekend nurse staffing · state 3.85 · national 3.43
Weekend RN hours
0.78
Weekend registered nurse coverage · state 0.85 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.79
CMS adjusted RN staffing hours
Adjusted total hours
3.13
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
35%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,668
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
11.15
Composite VBP score used to determine payment impact.
Payment multiplier
0.9810
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.81
Baseline 19.65% · Performance 21.06% · Measure score 0.81 · Achievement 0.81 · Improvement 0
Healthcare-associated infections
0
Baseline 7.31% · Performance 8.43% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.65
Baseline 48.19% · Performance 48.75% · Measure score 3.65 · Achievement 3.65 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.25 hours · Performance 2.80 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 109 · Observed rate 14.68% · Lower 95% interval 8.13% |
| Discharge to community | 27.59% |
50.57%
23 pts worse
|
Worse than the National Rate · Eligible stays 58 · Observed rate 13.79% · Lower 95% interval 18.35% |
| Medicare spending per beneficiary | 1.27 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 99.16% |
95.27%
3.9 pts better
|
Numerator 237 · Denominator 239 |
| Falls with major injury | 0.84% |
0.77%
0.1 pts worse
|
Numerator 2 · Denominator 239 |
| Discharge self-care score | 23.66% |
53.69%
30 pts worse
|
Numerator 31 · Denominator 131 |
| Discharge mobility score | 12.21% |
50.94%
38.7 pts worse
|
Numerator 16 · Denominator 131 |
| Pressure ulcers or injuries, new or worsened | 2.93% |
2.29%
0.6 pts worse
|
Numerator 7 · Denominator 239 · Adjusted rate 2.59% |
| Healthcare-associated infections requiring hospitalization | 8.42% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 98 · Observed rate 11.22% · Lower 95% interval 5.78% |
| Staff COVID-19 vaccination coverage | 26.88% |
8.2%
18.7 pts better
|
Numerator 75 · Denominator 279 |
| Staff flu vaccination coverage | 35.48% |
42%
6.5 pts worse
|
Numerator 99 · Denominator 279 |
| Discharge function score | 29.01% |
56.45%
27.4 pts worse
|
Numerator 38 · Denominator 131 |
| Transfer of health information to provider | 98.94% |
95.95%
3 pts better
|
Numerator 93 · Denominator 94 |
| Transfer of health information to patient | 84% |
96.28%
12.3 pts worse
|
Numerator 21 · Denominator 25 |
| Resident COVID-19 vaccinations up to date | 19.47% |
25.2%
5.7 pts worse
|
Numerator 22 · Denominator 113 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.8
0.4 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.9 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.5
0.5 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.1 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 78.6% |
91.5%
12.9 pts worse
|
93.4%
14.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 86.2% · Q2 81.2% · Q3 76.3% · Q4 70.4% · 4Q avg 78.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 83.3% |
89.6%
6.3 pts worse
|
95.5%
12.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 83.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
2.3%
1 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 1.0% · Q3 1.4% · Q4 2.5% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.2% |
4.9%
3.7 pts better
|
11.4%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.8% · Q3 0.5% · Q4 0.6% · 4Q avg 1.2% |
| Percentage of long-stay residents who lose too much weight | 7.1% |
5.6%
1.5 pts worse
|
5.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 9.0% · Q3 6.4% · Q4 5.7% · 4Q avg 7.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.2% |
22.2%
3 pts better
|
19.6%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.8% · Q2 16.6% · Q3 18.4% · Q4 21.9% · 4Q avg 19.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 39.8% |
18.5%
21.3 pts worse
|
16.7%
23.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.1% · Q2 27.9% · Q3 35.6% · Q4 60.7% · 4Q avg 39.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.1% |
0.1%
About the same
|
0.1%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.5% · 4Q avg 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.1% |
19.1%
8 pts better
|
16.3%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 6.5% · Q3 5.6% · Q4 21.0% · 4Q avg 11.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.1% |
14.2%
3.1 pts better
|
14.9%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 5.0% · Q3 12.0% · Q4 19.6% · 4Q avg 11.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.8% |
1.8%
1 pts worse
|
1.0%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 4.1% · Q3 2.4% · Q4 2.4% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
1.8%
1.2 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.5% · Q4 0.5% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.0% |
16.5%
0.5 pts worse
|
19.8%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 16.1% · Q3 19.0% · Q4 12.8% · 4Q avg 17.0% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
5.5%
0.1 pts better
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 4.2% · Q3 6.5% · Q4 6.5% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 66.5% |
84.1%
17.6 pts worse
|
81.7%
15.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 78.2% · Q2 71.1% · Q3 58.3% · Q4 55.4% · 4Q avg 66.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.7% |
9.8%
3.1 pts better
|
12.0%
5.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.7% · Observed 8.5% · Expected 14.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 8.2% |
1.6%
6.6 pts worse
|
1.6%
6.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 4.3% · Q3 9.5% · Q4 7.1% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 69.0% |
80.7%
11.7 pts worse
|
79.7%
10.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 69.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.4% |
23.4%
8 pts worse
|
23.9%
7.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.4% · Observed 37.7% · Expected 28.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-15 · Fire 2024-03-15
16 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
11 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2023-02-21 · Fire 2023-02-21
19 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
23 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (7 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-02-14
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-03-11
E · Potential for more than minimal harm
2025-02-14
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-03-11
E · Potential for more than minimal harm
2025-02-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-11
E · Potential for more than minimal harm
2025-02-14
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-03-11
E · Potential for more than minimal harm
2025-02-14
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 2025-03-11
E · Potential for more than minimal harm
2025-02-14
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-14
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-14
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-14
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-03-11
F · Potential for more than minimal harm
2024-03-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-04-23
E · Potential for more than minimal harm
2024-03-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-23
E · Potential for more than minimal harm
2024-03-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-23
E · Potential for more than minimal harm
2024-03-15
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-04-23
E · Potential for more than minimal harm
2024-03-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-23
E · Potential for more than minimal harm
2024-03-15
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-04-23
E · Potential for more than minimal harm
2024-03-15
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-04-23
E · Potential for more than minimal harm
2024-03-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-23
E · Potential for more than minimal harm
2024-03-15
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-04-23
D · Potential for more than minimal harm
2024-03-15
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2024-04-23
D · Potential for more than minimal harm
2024-03-15
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-04-23
F · Potential for more than minimal harm
2023-02-21
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-03-31
F · Potential for more than minimal harm
2023-02-21
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-03-31
F · Potential for more than minimal harm
2023-02-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-31
F · Potential for more than minimal harm
2023-02-21
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-03-31
F · Potential for more than minimal harm
2023-02-21
K909 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas and vacuum piping is labeled.
Corrected 2023-03-31
F · Potential for more than minimal harm
2023-02-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-31
F · Potential for more than minimal harm
2023-02-21
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-03-31
F · Potential for more than minimal harm
2023-02-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-03-31
E · Potential for more than minimal harm
2023-02-21
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-03-31
E · Potential for more than minimal harm
2023-02-21
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2023-03-31
E · Potential for more than minimal harm
2023-02-21
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-03-31
E · Potential for more than minimal harm
2023-02-21
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-03-31
E · Potential for more than minimal harm
2023-02-21
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-03-31
E · Potential for more than minimal harm
2023-02-21
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-03-31
E · Potential for more than minimal harm
2023-02-21
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-03-31
E · Potential for more than minimal harm
2023-02-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-03-31
E · Potential for more than minimal harm
2023-02-21
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-03-31
E · Potential for more than minimal harm
2023-02-21
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-03-31
E · Potential for more than minimal harm
2023-02-21
K907 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure medical gas and vacuum systems have documented maintenance programs.
Corrected 2023-03-31
E · Potential for more than minimal harm
2023-02-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-31
D · Potential for more than minimal harm
2023-02-21
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2023-03-31
D · Potential for more than minimal harm
2023-02-21
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-03-31
D · Potential for more than minimal harm
2023-02-21
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-03-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-02-14
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-03-11
E · Potential for more than minimal harm
2025-02-14
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 2025-03-11
D · Potential for more than minimal harm
2025-02-14
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-14
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 2025-03-11
D · Potential for more than minimal harm
2025-02-14
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-14
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-14
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-14
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-14
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-11
J · Immediate jeopardy
2024-10-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-12
D · Potential for more than minimal harm
2024-10-29
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 2024-12-12
F · Potential for more than minimal harm
2024-03-15
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 2024-04-10
E · Potential for more than minimal harm
2024-03-15
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-04-10
D · Potential for more than minimal harm
2024-03-15
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 2024-04-10
D · Potential for more than minimal harm
2024-03-15
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-04-10
D · Potential for more than minimal harm
2024-03-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-04-10
D · Potential for more than minimal harm
2024-03-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-10
D · Potential for more than minimal harm
2024-03-15
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-04-10
D · Potential for more than minimal harm
2024-03-15
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 2024-04-10
D · Potential for more than minimal harm
2024-03-15
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-04-10
D · Potential for more than minimal harm
2024-03-15
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-04-10
D · Potential for more than minimal harm
2024-03-15
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-04-10
D · Potential for more than minimal harm
2024-03-15
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 2024-04-10
D · Potential for more than minimal harm
2024-03-15
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-04-10
D · Potential for more than minimal harm
2024-03-15
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-04-10
G · Actual harm
2023-02-21
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 2023-04-14
F · Potential for more than minimal harm
2023-02-21
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 2023-03-27
F · Potential for more than minimal harm
2023-02-21
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2023-03-27
E · Potential for more than minimal harm
2023-02-21
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-02-21
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 2023-03-27
D · Potential for more than minimal harm
2023-02-21
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-02-21
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-02-21
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-02-21
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-02-21
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-02-21
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 2023-03-27
D · Potential for more than minimal harm
2023-02-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-02-21
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-02-21
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 2023-03-27
D · Potential for more than minimal harm
2023-02-21
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 2023-03-27
D · Potential for more than minimal harm
2023-02-21
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-02-21
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-02-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-27
C · Minimal harm
2023-02-21
F841 · Nursing and Physician Services Deficiencies
Health
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Corrected 2023-03-27
Penalties and ownership
What sits behind the stars
$40,359
2024-10-29
Fine
Fine · fine $40,359
Fine
Ownership
Lee, Il
5% Or Greater Direct Ownership Interest · Individual
Lee, Joan
5% Or Greater Direct Ownership Interest · Individual
Barrera, Odessa
Operational/Managerial Control · Individual
Lee Hospital Consulting Inc
Operational/Managerial Control · Organization
Lee, Il
Operational/Managerial Control · Individual
Lee, Il
Corporate Officer · Individual
Lee, Joan
Operational/Managerial Control · Individual
Lee, Joan
Corporate Officer · Individual
Lopez, Mark
Operational/Managerial Control · Individual
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