Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at La Salle County Nursing Home during CMS and state inspections, most recent first.
During a kitchen malfunction, the facility failed to follow its emergency menu, providing residents with fewer graham crackers than required. Staff confirmed the discrepancy, and a resident reported feeling hungry after breakfast. The Registered Dietician noted the importance of adhering to the menu for proper carbohydrate intake.
A resident experienced a significant weight loss of 10.2% in one month and 12.9% over six months, which was not addressed by the facility. Despite the facility's policy requiring investigation and notification of significant weight changes, the dietary manager and physician were not informed. The resident, who was on a regular diet, frequently paced the facility and refused meals, yet staff observations were not effectively communicated to address the issue.
The facility failed to date opened food items and adhere to equipment cleaning schedules, potentially affecting all 59 residents. Observations showed undated cereal and thickened liquids, and a container of eggs kept beyond the safe usage timeframe. The deep fryer and convection oven were not cleaned as required, with the fryer containing dark brown oil and burnt food.
The facility did not ensure all required staff attended the QAPI meeting, as the previous Administrator was absent. This absence was confirmed by the DON and documented in the meeting records, potentially affecting all 59 residents.
The facility's Antibiotic Stewardship Program was found to be incomplete and inaccurate, with missing information in the Monthly Infection Control Logs for May and June 2024. The logs lacked critical details such as infection onset dates, culture results, and symptoms supporting antibiotic use. The Infection Preventionist had not started the logs for July or August, potentially affecting all 59 residents in the facility.
A resident's call device was found on the floor and out of reach, contrary to facility policy. The resident, who requires assistance due to incontinence and other medical conditions, stated they use the call light for help. A unit attendant confirmed the device was on the floor, possibly having fallen earlier. The resident's care plan emphasizes the importance of having the call light within reach.
A facility failed to perform a PASRR rescreen for a resident after a severe mental illness diagnosis was added. The resident was admitted with Unspecified Psychosis, confirmed later, but the initial PASRR Level I screening did not require a Level II assessment. Staff interviews revealed a lack of awareness and coordination regarding the updated diagnosis, leading to the oversight.
A facility failed to conduct required respiratory assessments before and after nebulizer treatments for a resident with COPD. An LPN administered the treatment without checking lung sounds or vital signs, contrary to facility policy. The DON confirmed the policy requirement but noted it was not being followed for scheduled treatments.
A facility failed to document a physician's rationale for continuing dual therapy for a resident receiving Trazodone and Melatonin for insomnia. Despite a pharmacy recommendation to discontinue one medication, the physician declined without providing the required rationale, as confirmed by the DON.
The facility failed to document the rationale for continued antibiotic use for two residents. One resident was on Macrobid for UTI prophylaxis without recent lab tests, while another was treated for a UTI despite urine culture results not indicating an infection. The facility did not adhere to its Antibiotic Stewardship-Infection Control policy.
The facility failed to ensure proper diagnoses and targeted behaviors for psychotropic medications for two residents. One resident was prescribed Lorazepam and Trazadone without documented diagnoses of anxiety or depression, and another was on Duloxetine, Mirtazapine, and Ativan without documented behaviors related to anxiety or depression. The facility's policy requires comprehensive assessments and documentation, which were not followed, leading to the deficiency.
Failure to Follow Emergency Menu During Kitchen Malfunction
Penalty
Summary
The facility failed to adhere to its emergency menu during a period when the kitchen was experiencing electrical issues, affecting the nutritional intake of residents. On January 29, 2025, residents were served an inadequate breakfast consisting of fewer graham crackers than specified in the emergency menu. The emergency menu for that day required six graham crackers, among other items, but residents received only one to two packages of crackers, which was insufficient to meet their nutritional needs. This discrepancy was confirmed by multiple staff members, including the Kitchen Manager and CNAs, who noted that the residents were served a smaller amount of food than required. The Registered Dietician emphasized the importance of following the menu to ensure residents receive the correct amount of carbohydrates. The facility's Administrator also confirmed receiving only two packages of crackers on her test tray, indicating a systemic issue in meal distribution. The failure to provide the specified amount of food led to at least one resident expressing hunger after breakfast, highlighting the impact of the deficiency on resident satisfaction and nutritional adequacy.
Failure to Address Severe Weight Loss in Resident
Penalty
Summary
The facility failed to identify and address a severe weight loss in a resident, resulting in a continued weight loss of 10.2% in one month and 12.9% over six months. The facility's policy required significant weight discrepancies to be investigated and reported to the physician and dietary department, but this was not done for the resident in question. The resident's weight records showed a significant decline, yet there was no documentation that the dietary manager or the resident's physician was notified of this weight loss. The resident was on a regular diet with no additional dietary orders, and there was an expectation for snacks to be offered three times a day. Observations revealed that the resident frequently paced the facility and was not seen in the dining room during mealtimes, often refusing to eat the meals provided. Staff members, including the Director of Nursing and Certified Nursing Assistants, noted the resident's increased activity and decreased focus, but there was no indication that these observations were communicated effectively to address the resident's nutritional needs. The Director of Nursing was unaware of the resident's recent weight loss, indicating a breakdown in communication and monitoring processes within the facility.
Failure to Date Opened Food Items and Clean Equipment
Penalty
Summary
The facility failed to adhere to its food storage and equipment cleaning policies, which has the potential to affect all 59 residents. Observations revealed that opened food items, such as cereal and thickened liquids, were not dated as required, and some items were kept beyond their safe usage timeframe. Specifically, containers of cereal and thickened liquids were found open and undated, and a container of whole liquid eggs was kept beyond the seven-day limit. The Dietary Manager confirmed these items should be dated upon opening and used within seven days. Additionally, the facility did not implement its cleaning schedule for food service equipment. The deep fryer was found with dark brown oil containing burnt food and crumbs, and the fryer baskets were covered in a greasy substance. The oil, which should be changed weekly, had not been filtered the previous night. The convection oven had a spill that was not cleaned as scheduled, leaving a dark brown crusty area. The District Dietary Manager confirmed that all opened foods should be covered and dated, and the equipment should be cleaned regularly.
Absence of Required Staff in QAPI Meeting
Penalty
Summary
The facility failed to ensure that all required staff attended the Quality Assurance Meetings, which are essential for maintaining the Quality Assurance and Performance Improvement (QAPI) program. According to the facility's policy, the QAPI committee must include specific members and meet at least quarterly. The committee is required to have the QAPI officer, Medical Director, Administrator, Director of Nursing, and several other key staff members. However, during the meeting on April 18, 2024, the previous Administrator was absent, as confirmed by the Director of Nursing. This absence was documented in the meeting records, which did not include the Administrator's signature. The facility had a census of 59 residents at the time of the report, indicating that the deficiency had the potential to affect all residents in the facility.
Incomplete Antibiotic Stewardship Program
Penalty
Summary
The facility failed to ensure that its Antibiotic Stewardship Program was complete, accurate, and conducted monthly for residents receiving antibiotics or having any type of infection. The facility's policy, named Antibiotic Stewardship-Infection Control Program, outlines procedures for monitoring antibiotic use, including tracking the reason for antibiotics, assessing appropriateness, and monitoring physician compliance. However, the facility's Monthly Infection Control Logs for May and June 2024 were incomplete, lacking critical information such as the date of infection onset, culture results, organism details, antibiotic resistance, and symptoms supporting antibiotic use. The Infection Preventionist admitted to not having started the Infection Control Logs for July or August, which should have been initiated at the beginning of each month to accurately track and monitor infections. This oversight has the potential to affect all 59 residents residing in the facility, as the logs are essential for ensuring appropriate treatment of infections. The deficiency highlights a significant gap in the facility's infection control practices, as the logs are not being maintained in accordance with the facility's policy.
Resident's Call Device Out of Reach
Penalty
Summary
The facility failed to ensure that a resident's call device was within reach, as required by their policy. During an observation, a resident was found sitting in a recliner with their call device on the floor, out of reach. The resident, who is on a water pill and requires assistance to use the bathroom, stated that they use the call light for help. A unit attendant confirmed that the call device was on the floor and speculated that it might have fallen when the resident got up earlier. The resident's care plan indicates a moderate risk for falls and includes an intervention to ensure the call light is within reach and to encourage its use for assistance. The resident's medical history includes incontinence, hemiplegia, a history of CVA, and the use of various medications.
Failure to Conduct PASRR Rescreen After New Diagnosis
Penalty
Summary
The facility failed to perform a Pre-Admission Screening and Resident Review (PASRR) rescreen for a resident after a diagnosis of severe mental illness was added. The resident, identified as R22, was admitted with a diagnosis of Unspecified Psychosis, which was later confirmed on 4/20/23. Despite this, the PASRR Level I screening conducted on 3/28/23 indicated that no Level II assessment was required, as it only noted situational symptoms and an anxiety disorder. The Minimum Data Set (MDS) assessment dated 6/20/23 documented psychiatric and mood disorders, including a psychotic disorder, and confirmed the use of antipsychotics. Interviews with facility staff revealed a lack of coordination and awareness regarding the resident's updated diagnosis. The Admissions Coordinator, V22, stated that they request a Level I screening upon admission and rely on the Social Service Director (SSD), V9, to coordinate further assessments if needed. However, V9 admitted to not being aware of the psychotic disorder diagnosis and confirmed that a new Level I screening should have been initiated. The MDS/Care Plan Coordinator, V6, also acknowledged the oversight, stating that the psychotic diagnosis was not marked on the admission MDS due to delayed verification from the doctor. This lack of timely action and communication led to the failure to conduct a necessary PASRR rescreen for the resident.
Failure to Conduct Respiratory Assessments for Nebulizer Treatments
Penalty
Summary
The facility failed to ensure a respiratory assessment was completed before and after nebulizer treatment for a resident with Chronic Obstructive Pulmonary Disease (COPD). The facility's policy requires that pre-treatment data such as pulse and breath sounds be noted, and post-treatment data including pulse, breath sounds, and any side effects be recorded in the medical record. However, during an observation, an LPN administered a nebulizer treatment to a resident without auscultating the resident's lungs or taking any vital signs before or after the treatment. The LPN confirmed that they did not perform these assessments, stating that they only do so if specifically ordered by a physician or if the treatment is administered on a prn basis for someone experiencing breathing issues. The Director of Nursing acknowledged that the facility's policy requires these assessments for all nebulizer treatments, including scheduled ones, but noted that this was not being followed for residents receiving regular treatments.
Failure to Document Rationale for Dual Therapy
Penalty
Summary
The facility failed to ensure that a physician documented a rationale for continuing dual therapy for a resident, identified as R53, who was receiving both Trazodone and Melatonin for insomnia. According to the facility's Psychotropic Medication Use policy, the physician or prescriber is required to document the clinical rationale for not attempting a dose reduction if it could impair the resident's function or increase distressed behavior. However, in this case, the physician's response to the pharmacy's recommendation to discontinue one of the medications was left blank, indicating a lack of documented rationale. The deficiency was identified during a review of R53's medical records, which included a Physician Order Sheet listing both medications for insomnia. A Consultation Report noted the duplicate therapy and recommended discontinuing one of the agents unless a documented assessment of risk versus benefit justified the dual therapy. Despite the recommendation, the physician declined to make any changes without providing the required rationale. This oversight was confirmed by the Director of Nursing, who acknowledged that the Nurse Practitioner had signed the report but failed to document the necessary rationale.
Failure to Document Rationale for Antibiotic Use
Penalty
Summary
The facility failed to document the rationale for the continued use of antibiotics for two residents, R16 and R51, which was identified during a review of unnecessary medications. For R16, the Physician Order Sheet indicated the use of Macrobid for UTI prophylaxis due to a personal history of urinary tract infections. However, there were no recent lab tests or urinalysis conducted to justify the continued use of the antibiotic. The Director of Nurses acknowledged that R16 was admitted with the antibiotic in place and, being on hospice care, the facility continued the medication without further evaluation. For R51, the resident was on Macrobid for a urinary tract infection, although the urine culture results did not indicate an active infection. Despite the absence of a high colony count, the physician ordered the antibiotic treatment. The Infection Control Preventionist confirmed that the urine culture did not support the presence of a UTI, yet the physician decided to proceed with the treatment. This lack of documentation and adherence to the facility's Antibiotic Stewardship-Infection Control policy contributed to the deficiency.
Failure to Ensure Proper Diagnoses for Psychotropic Medications
Penalty
Summary
The facility failed to ensure proper diagnoses and targeted behaviors were in place for psychotropic medications for two residents, R53 and R49, out of a sample of 27. For R53, the facility's records showed prescriptions for Lorazepam and Trazadone, intended for anxiety and insomnia, respectively. However, there were no documented diagnoses of anxiety or depression in R53's clinical records, which are necessary to justify the use of these medications. Observations of R53 showed no aggressive or harmful behaviors, and the facility's staff confirmed the absence of specific targeted behaviors in the resident's records. Similarly, for R49, the facility's records indicated the use of Duloxetine, Mirtazapine, and Ativan for anxiety and depression. Despite this, there were no documented behaviors related to these conditions, and the staff confirmed that R49 generally did well without any significant behavioral issues. The Director of Nursing acknowledged the lack of specific targeted behaviors documented for R49, relying instead on generic behavior tracking by CNAs. The facility's policy on psychotropic medication use requires a comprehensive assessment and documentation of necessity by the prescribing physician, which was not adhered to in these cases. The absence of specific diagnoses and targeted behaviors for the psychotropic medications prescribed to R53 and R49 indicates a failure to comply with the facility's policy and regulatory requirements, leading to the identified deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ottawa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pleasant View Luther Home | 2.6 mi | ★★★★★ | 3 | 0 |
| Pavilion Of Ottawa | 3.4 mi | ★★★★★ | 11 | 0 |
| Goldwater Care Marseilles | 9.2 mi | ★★★★★ | 12 | 0 |
| Manor Court Of Peru | 11.8 mi | ★★★★★ | 11 | 1 |
| Allure Of Peru | 11.8 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.