Health inspection·November 3, 2023

F 0656 behind R5 in the dining room making light contact. Summary indicates R1 was moved immediately. Level of Harm - Minimal harm or potential for actual harm R5's care plan did not include focus area to include R5 as recipient of R1's behaviors or interventions to prevent future incidents. Residents Affected - Some On 11/2/23 at 2:30pm V3, SSD (Social Service Director) stated she is responsible for behavior care planning and R1, R2, R3, R4 and R5's care plans should have been either updated or developed after each incident. 5.) Email dated 6/23/23 at 12:05pm (from facility to Ombudsman) indicates R6 was having safety issues with her electric wheelchair. Email indicates R6 pinned a staff member against a soda machine, got the wheelchair footrests stuck under her bed - requiring assistance to get unstuck and (on 6/23/23) rammed her feet under her bed causing a gash on top of her foot requiring stitches. Email indicates R6 was very upset when told she must use a manual wheelchair until an electric wheelchair evaluation could be done. Email indicates the facility is also concerned about the safety of other residents. Nurse Note dated 8/10/23 at 10:15am indicates that when given a new manual wheelchair to use, R6 stated her plan was to move to another facility where she would be able to use her motorized chair. Note indicates at that time, R6 was advised that once insurance is submitted for a custom chair - her electric chair would no longer be covered. Note indicates R6 was adamant that she did not want a custom manual chair and wanted to keep her electric chair covered. Nurse Note dated 8/11/23 at 10:30am indicates staff told R6 the reason she is not allowed to use her electric wheelchair is because R6 cannot safely operate the chair. Note indicates R6 became agitated and yelling that it was the facility's fault. Nurse Note dated 9/12/23 at 2:00pm indicates R6 wanted to know when she would be getting her electric wheelchair returned. Note indicates R6 stated that her independence is being taken away. Nurse Note dated 10/4/23 at 10:30am indicates R6 upset and tearful over electric wheelchair - upset that she is not able to use motorized wheelchair in the facility. Nurse Note dated 10/5/23 at 10:06pm indicates R6 became very tearful in the dining room and was upset that she is not able to use her motorized chair. Note indicates R6 feels she is not able to do the things she would like to do because her chair is not comfortable. Note indicates R6 was worried about her warranty being voided on her motorized chair. Email dated 10/10/23 at 10:59am (Ombudsman to facility) indicates R6 is asking about her electric wheelchair Insisting it be returned to her. On 11/2/23 at 9:45am V1 (Administrator) stated (R6) is just not safe in the electric wheelchair. She is still upset, obsessed with losing her chair. Not rational when staff try to explain the reasons, she can't use it in the facility. On 11/2/23 at 1pm R6 was in her room in a large reclining wheelchair. At that time R6 stated I have to wait now for staff to take me wherever I want to go. I have no life now. I'm actively looking for a group home I can go to. I'm not happy here. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146116 If continuation sheet Page 2 of 4 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 11/03/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete R6's current care plan does not address R6's unsafe behavior or incidence as related to R6's electric wheelchair and does not address the resulting psycho-social impact on R6's wellbeing. On 11/2/23 at 3:00pm V1 (Administrator) stated she was unaware a care plan had not been developed to address the issues with R6's electric wheelchair or R6's difficulty adjusting to its loss. V1 stated V3 should have added these areas to R6's care plan. Event ID: Facility ID: 146116 If continuation sheet Page 3 of 4 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 11/03/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to revise the comprehensive care plan for two residents (R2, R4) of six residents reviewed for resident-to-resident altercations. Findings include: Social Service Director Job Description, Essential Duties and Responsibilities dated 6/5/17 documents: Complete MDS (Minimum Data Set) assessments (Cognitive, Mood, Behavior, Hearing, Vision, Speech, and Discharge) and identify problems, concerns, goals, and interventions through developing and updating the Plan of Care according to Federal and State Regulations. Current Physician Order Summary Report indicates R1 was admitted to the facility on [DATE] with diagnoses of Dementia with Agitation, Alzheimer's Disease and Anxiety Disorder. Current Physician Order Summary Report indicates R2 was admitted to the facility on [DATE] with diagnoses of Dementia with Behavioral Disturbance, Cognitive Communication Deficit and Anxiety Disorder. Incident Investigation Summary (undated) indicates on 10/13/23 R1 wheeled up (in her wheelchair) to R2 and was cursing at R2. Summary indicates R2 then grabbed R1's arm and tapped R1 three times. Summary indicates R2 stated that R1 had hit her first. R2's current care plan indicates R2 had a recent incident (10/13/23) of hitting another resident on the arm and R2 can become verbal with other confused residents and engage in yelling or arguments. R2's care plan was not revised to include any specific interventions to prevent further resident to resident altercations. 2) Current Physician Order Summary Report indicates R4 was admitted to the facility on [DATE] with diagnoses of Dementia without Behavioral Disturbance, Other Psychotic Disorder and Anxiety Disorder. Incident Investigation Summary (undated) indicates on 10/19/23 R1 wheeled up (in her wheelchair) to R4 and pushed/slapped at R4's shoulder. R4's current care plan indicates R4 wanders aimlessly and significantly intrudes on the privacy (of others) and/or activities. R4's care plan was not revised to include incident with R1 and did not include interventions to prevent further resident to resident altercation. On 11/2/23 at 2:30pm V3 (Social Service Director) stated she is responsible for behavior care planning and R2 and R4's care plans should have been either updated or developed after each incident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146116 If continuation sheet Page 4 of 4