Health inspection·July 5, 2023

F 0689 Level of Harm - Actual harm the foot portion of the wheelchair being under R3's bed with R3's foot being trapped between the bed and the wheelchair. An injury was noted to R3's left foot with a 4.4 cm (centimeter) in length laceration to the upper portion of left foot with drainage and underlying exposed tissue. Summary indicates R3 stated she got her foot stuck under the bed. R3 was sent to the hospital for treatment and returned with six sutures. Residents Affected - Few Nurse Note dated 6/23/23 at 7:37am indicates staff were called to R3's room, Large gash to top of left foot 4.4 inches long, fatty layer exposed. Note indicates efforts were made by staff to close wound and gauze wrapped to control bleeding; top of foot starting to bruise. Note indicates physician notified with orders to send to hospital via 911. Note indicates R3 stated her foot became stuck under bed while in electric wheelchair and obtained laceration to top of left foot. Nurse Note dated 6/23/23 at 11:14am indicates R3 returned from the hospital via ambulance with stitches to left foot and wrapped with supportive bandages. Nurse Note dated 6/23/23/at 11:52am indicates R3's Family/POA (Power of Attorney) was notified of incident of R3 running into her bed with her electric wheelchair causing injury to left foot. Note indicates this incident follows the incident regarding (R3) pinning a staff member against the vending machine causing her to be off work. Note also indicates Staff have had to get her electric wheelchair unstuck from her bed before. Note indicates This causes a safety concern regarding her and other residents. POA was notified of safety concerns and need for a wheelchair evaluation. A regular wheelchair will be used until the evaluations completed. Ombudsman updated with our concern with electric wheelchair and safety concerns. Nurse Note dated 6/26/23 at 4:03pm indicates staff spoke with motorized wheelchair company regarding R3 electric wheelchair, appointment made for them to come out and assess electric wheelchair and speeds, scheduled for 7/18/2023. Motorized Wheelchair Evaluation Form dated 2/6/23 (admission) and 5/3/23 (quarterly) both indicate R3: Does have a physical limitation that prevents R3 from accomplishing mobility-related activities of daily living. Does not have the mental capacity sufficient for safe operation of mobility-related functions with the use of a motorized wheelchair. Is unable to be trained for safe operation of a motorized wheelchair. Wheelchair Clinic Form dated 6/26/23 for Electric wheelchair indicates (R3) was assessed for her ability to operate her wheelchair in several environments. In close conditions within resident room during which (R3) had light contact with several objects due to delayed reactions with a possible solution being to reduce the top speed of the propulsion of her wheelchair in which (R3) was highly resistant to the idea. Wheelchair Clinic Form dated 6/26/23 for Standard wheelchair indicates (R3) evaluated for fit in a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146116 If continuation sheet Page 2 of 3 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 07/05/2023 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 0689 standard wheelchair following difficulties encountered in operation of her electric wheelchair with two accidents involved. Level of Harm - Actual harm Residents Affected - Few On 7/5/23 at 2:30pm V7 (Restorative Registered Nurse) stated I do believe (R3) is a little at risk for accidents - a safety issue. I believe the speed needs to be reduced on the chair, but (R3) won't even hear of it. V7 stated he became aware of R3's accident with the employee through the nurse note later documented on 6/26/23. No one told me about the incident when it happened. I should have been told and I didn't know of any other incidents with her feet or footrests getting stuck under her bed until now. V7 stated R3's motorized chair was taken away after she injured her foot, but the other chairs didn't fit her right, so they had to put R3 back in her motorized chair. V7 stated they are unable to adjust the speeds so the company will come out to adjust. V7 further stated he didn't know why he documented that R3 did not have mental capacity to operate the motorized chair and couldn't be trained in the admission and quarterly assessments. Care Plan dated 2/17/23 indicates R3 has an electric wheelchair which R3 uses on a consistent basis with intervention to assess speed setting quarterly and as needed. Care Plan was not updated/revised to include R3 pinning staff against the wall, any incidents with R3's feet or footrests becoming stuck under her bed or the incident causing injury to R3's foot. On 7/6/23 V1 (Administrator) stated that the facility did not have a Motorized Wheelchair Policy or Consent until 7/6/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146116 If continuation sheet Page 3 of 3