Health inspection·July 21, 2022

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146116 If continuation sheet Page 2 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146116 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Salle County Nursing Home 1380 North 27th Road Ottawa, IL 61350 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 that brace. Level of Harm - Minimal harm or potential for actual harm 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. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146116 If continuation sheet Page 3 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146116 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Salle County Nursing Home 1380 North 27th Road Ottawa, IL 61350 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146116 If continuation sheet Page 4 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146116 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Salle County Nursing Home 1380 North 27th Road Ottawa, IL 61350 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm 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. Residents Affected - Few 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. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146116 If continuation sheet Page 5 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146116 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Salle County Nursing Home 1380 North 27th Road Ottawa, IL 61350 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146116 If continuation sheet Page 6 of 6