Health inspection·August 18, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents received scheduled showers for one resident (R49) of two residents reviewed for ADLs/Activities of Daily Living in a sample of 27. Residents Affected - Few Findings include: The facility's Bathing and Showering, ADL's policy, and procedure, modified 8-16-23, documents Policies: 2. Each resident shall be scheduled for a shower twice a week and as is necessary to maintain personal hygiene, with showers being scheduled on every shift. Shower times may be changed on resident request and according to resident needs. Should the resident refuse hygiene cares by becoming combative, resistant, or other difficulties in cares, these refusals shall be documented in the resident's clinical record either in (name of software) or in the nursing record. And 12. Record skin observations on Skin Audit sheet. If a resident refuses a shower, then the Skin Audit sheet must be filed out indicating that the resident has refused the shower, including whom the shower was to be performed and by whom. A skin Audit sheet must be performed on all residents who are SCHEDULED to receive a shower. All skin Audit sheets are to be submitted to the mailbox of the Wound Nurse/Infection Preventionist. On 8-15-23, at 10:58am, R49 was sleeping on a couch in the lounge area across from the nurses' station with messy, greasy hair. On 8-17-23, at 3:20pm, R49 was sleeping on a couch in the same lounge area. R49's hair appears greasy. R49 looks unkempt. On 8-18-23, at 8:35am, R49 was awake and in pajamas out in the facility's front lobby area lounging in a chair. R49 appears unkempt with greasy, messy hair. On 8-18-23, at 8:50am, while R11 was ambulating the hallways, R11 complained of R49 being dirty and sleeping on the facility's couches and chairs. On 8-18-23, at 9:28am, R49 was sleeping on a couch in the lounge area across from the nurses' station. R49 looks unkempt with greasy, messy hair. R49's current Physician Order Sheet/POS includes the diagnoses of Unspecified Dementia, Urinary incontinence, and Cognitive communication deficit. R49's MDS (Minimum Data Set) assessment, dated 7-18-23, documents R49 requires physical assist with one person for bathing, is frequently incontinent of bladder, and occasionally incontinent of bowel. R49's current Care plan includes The resident is resistive to care: has not wanted to get out of bed or changed when incontinent. (R49) can become verbal with other confused residents and engage in yelling or arguments. Interventions include: If resident resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again. The facility's A Wing Shower Days list document R49 is to get a shower on day shift on Tuesday and Friday with hair washed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146116 If continuation sheet Page 2 of 10 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 08/18/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 8-17-23, at 3:00pm V11 (MDS/Care plan Coordinator) was unable to produce any Shower sheets (Skin Audit sheets) for July or August 2023 for R49. V11 stated they should be doing them and agreed that without them there is no documentation of R49 receiving shower. On 8-18-23, at 9:07am, V2 (Director of Nursing/DON) stated the following: (R49) can be difficult with cares. Her motivation is when she is going out with her male friend. (R49) doesn't get physical, but loud and agitated. The staff are to back off then re-approach. If a resident is refusing, the girls (staff) should mark shower sheets and turn into the nurse. V2 confirmed there haven't been shower sheets for R49 in quite a while. They (staff) should be documenting in notes or on the shower sheets, so we know (R49's) refusing. If a resident refuses a shower, then they should get a full bed bath. V2 continued to state that R49's Progress notes say that on August 18(R49) got cleaned up, but it doesn't say (R49) was showered. At this time, V2 confirmed the last documented shower for R49 was on 7-19-23 according to progress notes. Event ID: Facility ID: 146116 If continuation sheet Page 3 of 10 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 08/18/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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. Based on observation, interview, and record review the facility failed to monitor refrigerated medication storage temperatures. This failure has the potential to affect all 59 residents in the facility. The facility also failed to ensure refrigerated controlled medications were double locked for four residents (R27, R29, R40, R45) during review for medication storage. Findings include: 1.) Facility Policy/Storage and Expiration Dating of medications and Biologicals dated/revised 8/7/23 documents: Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopoeia guidelines for temperature ranges. Refrigeration: 36 degrees Fahrenheit (F) to 46 degrees (F). Facility should monitor the temperature of medication storage areas at least once a day. Facility Policy/Refrigerator Cleaning dated 7/23 documents: Midnight Licensed staff monitors the temperatures of all refrigerators on the nursing unit nightly and documents on the form provided. Report temperatures over 40 degrees (F) to maintenance as soon as possible. Resident Census and Condition Report indicates 59 total residents in the facility on 8/15/23. Refrigerator/Freezer Temperature Logs dated July and August 2023 document: Standard: 41 degrees (F) or colder - Refrigerator July 2023 Log - Temperatures documented only for July 19, 20 and 26 - 31. July 19 and 20 were documented at 30 degrees (F) and July 26 to July 30 were documented at 32 degrees (F). August 2023 Log - Temperatures only documented for August 1, 4, 6 - 8 and 11-16. On 8/17/23 at 11:35am V5 (Registered Nurse) stated night shift checks and records the temperature of the medication refrigerator. V5 confirmed there is only one medication room/medication refrigerator in the facility which receives medications for all facility residents. 2.) Facility Policy/Storage and Expiration Dating of Medications, Biologicals dated/revised 8/7/23 documents: Controlled Substances Storage: Controlled Substances stored in the refrigerator must be in a separate container and double locked. On 8/17/23 at 11:30am facility medication storage room contained one refrigerator with a latch that was unlocked with a padlock sitting next to the latch directly on top of the refrigerator. The medication room refrigerator contained unopened controlled medications for the following residents: Liquid Morphine (opiate/narcotic) - R27, R29, R40, R45 Liquid Lorazepam (benzodiazepine) - R45 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146116 If continuation sheet Page 4 of 10 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 08/18/2023 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 0761 V5 (Registered Nurse) stated I really don't know, but I'm assuming since there are narcotics in the refrigerator it should be locked. The narcotics in the medication cart need to be double locked. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146116 If continuation sheet Page 5 of 10 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 08/18/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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. Based on observation, interview and record review the facility failed to provide meals according to the menu. This failure has the potential to affect all 59 residents in the facility who receive meals from the kitchen. Findings include: Facility Policy/Menus dated/revised 2017 documents: Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal. Resident Census and Condition Report indicates 59 total residents in the facility on 8/15/23. On 8/18/23 at 12:45pm V1 (Administrator) stated that all 59 residents in the facility receive meals from the kitchen. Facility Week at a Glance Menu, dated 8/8/23, documents that the scheduled Lunch Meal for 8/15/23 at 12:00 pm was Marinated Chicken Thighs, Sugar Snap Peas, Oven [NAME] potatoes, Dinner Roll and Chocolate Chip cookies. On 8/15/23, at 12:30pm, V4 (Dietary Manager) stated, Our menu is wrong. We prepared the wrong week's food on our Week at a Glance. The meal today should have been chicken thighs, peas, and potatoes, but my staff prepared ham, sweet potatoes, and spinach instead. We have new workers in the kitchen, and they messed up the weeks on our menu. On 8/16/23 at 11:15am All nine residents (R5, R8, R11, R12, R23, R28, R42, R46, R50) attending a group meeting at that time stated that meals were not following the menus posted and all nine agreed the meal served not matching the meal posted had been going on for a while and believed it was due to constantly changing dietary staff. Food Committee Meeting notes dated June 15, 2023 indicate Residents complained when meal tickets are made with changes, they don't always get what they have chosen. Food Committee Meeting notes dated July 20, 2023 indicate Residents are upset with menus being changed. They would like to know when menu is being changed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146116 If continuation sheet Page 6 of 10 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 08/18/2023 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on interview and record review the facility failed to provide/offer bedtime snacks to nine residents (R5, R8, R11, R12, R23, R28, R42, R46, R50) of nine residents who attended a group meeting in the sample of 27. Findings include: Facility Policy/Snacks dated/revised 9/2017 documents: Bedtime snacks will be provided for all residents. Nursing services is responsible for delivering the individual snacks to the identified residents and for offering evening snacks to all other residents. On 8/16/23 at 11:10 am, all nine residents attending a group meeting at that time stated that bedtime snacks were offered sporadically. We might get them, or we might not. Food Committee Meeting notes dated June 15, 2023 indicate Residents reported that the snacks aren't available or being passed out. On 8/16/23 at 2:53pm V4 (Dietary Manager) stated All CCD (diabetic) snacks are labeled. The bucket containing snacks is on the snack cart which is left at the nurse's station. CNAs (Certified Nurse Assistants) are supposed to go around and offer snacks at night. Sometimes the snack cart comes back in the morning and nothing has been touched including the CCD snacks. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146116 If continuation sheet Page 7 of 10 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 08/18/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to administer medications without touching with bare hands, cleanse a glucometer, perform handwashing between glove changes, cleanse a bedside table to prevent cross contamination, and change gloves with cares for five (R11, R29, R40, R42, R45) out of 24 residents reviewed for infection control in a sample of 27. Residents Affected - Some Findings include: Facility Infection Control Glove Technique, dated 3/14, documents Change gloves between tasks and procedures on the same resident after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident, and wash hands immediately to avoid transfer of microorganisms to other resident or environments. Remove gloves, dispose of gloves in the regular trash, and wash hands or Facility Infection Control program policy and procedures, undated, documents Preventing the spread of infection procedures must be followed to prevent cross-contamination; including handwashing and/or changing gloves after performing personal care, or when performing tasks that provide the opportunity for cross-contamination to occur (i.e., facility equipment). 1.) On 8/17/23 at 10:37am, V7 (Registered Nurse/RN) went into R40's room to perform cares. V7 grabbed R256's overbed table to perform cares for R40. After cares for R40, V7 did not cleanse R256's overbed table. V7 then placed R256's overbed table back on R256's side of the room and left the room. On 8/17/23 at 10:37am, V7 (RN) stated I usually use a cleanser with 70 percent alcohol on the bedside table after I do cares for (R40). I did not have the cleanser on my cart, so I did not clean (R256's) table after I used it for (R40). 2.) On 8/17/23 at 9:21, R45 was in bed in her room. On 8/17/23 at 10:10am, V7 (RN) was performing wound cares with R45 when R45 became incontinent of stool. V7 grabbed R45's incontinence brief and pushed R45's incontinence brief full of stool together and down under R45's buttocks, and without changing V7's gloves, V7 used the same gloves to put on R45's new dressing. V7 then snapped R45's stool filled brief back on over R45's new dressing. On 8/17/23 at 11:55am, V7 RN stated, I should have changed (R45) when she was incontinent of stool and changed my gloves before doing the dressing change. 3.) On 8/17/23 at 1:15pm, R29 was lying in bed. At that same time, V10 (Certified Nurse Assistant/CNA) performed personal cares for R29. After performing personal cares for R29, V10 did not wash her hands or use waterless hand antiseptic between glove changes. V10 put on new gloves and put on R29's new brief. V10 did not wash her hands or use waterless hand antiseptic after changing her gloves and grabbed R29's two blankets and put on R29. On 8/17/23 at 1:20pm, V10 stated I should have washed my hands between glove changes. 4) Facility Policy/Glucometer Decontamination dated 2012 documents: The glucometer will be decontaminated with the facility approved wipes following use on each resident. After performing the glucometer testing, the nurse shall perform hand hygiene, don gloves, and use the disinfectant wipe to clean all external parts of the glucometer. A specific amount of contact time is not required for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146116 If continuation sheet Page 8 of 10 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 08/18/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cleaning. A second wipe shall be used to disinfect the glucometer, allowing the meter to remain wet for the contact time required by the disinfectant label. The clean glucometer will be placed on a paper towel. On 8/17/23 at 11:30am V8 (RN) performed a blood glucose test for R11 which required extracting a drop of blood from R11's finger. After completing the blood glucose test, V8 administered insulin to R11, returned to the medication cart and put the glucometer back into the top drawer of the medication cart and closed the drawer. On 8/17/23 at 11:35am V8 stated I forgot to clean the glucometer, I usually clean after I used it. V8 then proceeded to remove the glucometer from the drawer, removed bleach wipes from the bottom drawer of the medication cart and wiped the glucometer for approximately 20 seconds and placed the glucometer on top of the medication cart. V8 stated she preferred to use bleach wipes, but product can change and All of them have different contact and cleaning times. Bleach wipe instruction for use indicate to clean/wipe surfaces of non-porous materials and to keep wet for three minutes. 5) Facility Policy/General Dose Preparation and Medication Administration dated/revised 1/1/13 documents: Facility staff should not touch the medication when opening a bottle or unit dose package. On 8/17/23 at 11:50am V5 (RN) dispensed one tablet of Reglan (antiemetic) 5mg (milligrams) into a medication cup. As V5 pushed the tablet through the foil seal, the tablet split into two halves. While preparing to administer the Reglan tablet to R42, the medication cup tipped over and both halves of the tablet spilled out onto the top of the medication cart. V5 then picked up both halves of the tablet with her bare hands, placed the halves back into their medication cup and administered the medication to R42. On 8/17/23 at 1:45pm V5 acknowledged she should have used gloves to pick up the Reglan from the cart before administering to R42. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146116 If continuation sheet Page 9 of 10 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 08/18/2023 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to provide consents for influenza vaccinations and provide documentation of vaccination education/potential side effects for five residents (R10, R16, R40, R45, R50) of five residents reviewed for immunizations in the sample of 27. Residents Affected - Some Findings include: Facility Policy/Infection Control Resident Immunizations and Vaccinations dated 7/31/17 documents: The resident's medical record shall include documentation that indicates, at a minimum, the following: That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization and that the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. On 8/17/23 at 11:00 am a request was made to V7 (Registered Nurse/RN) and V9 (RN/Infection Preventionist) for influenza and pneumococcal vaccination documentation including consents for five residents (R10, R16, R40, R45, R50). On 8/17/23 at 12:00pm a handwritten list of dates of vaccination for influenza (flu) and pneumatically vaccinations were presented for R10, R16, R40, R45 and R50. At that time V9 stated that she only verbally received consent for the flu vaccinations given to R10, R16 and R40 in October 2022. V9 stated that R45's flu vaccination was historical and R50 had no record of flu immunization although was admitted in February of 2023. V9 stated that there is no written consent or education on benefits or side effects in the medical records. The handwritten list of dates of vaccinations for R10, R16, R40, R45 and R50 indicates I called the families. They gave verbal consent, but it's not charted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146116 If continuation sheet Page 10 of 10