F 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Level of Harm - Actual harm
Residents Affected - Few
Based on interview and record review the facility failed to implement fall interventions for a resident at risk
for falls for one of three residents (R1) reviewed for falls in a sample of three. This failure resulted in R1
experiencing an unwitnessed fall, subsequently sustaining a left hip fracture requiring surgical repair.
Findings include:
R1's admission Fall Risk Assessment, dated 2/2/24 documents that R1 is at risk for falls.
R1's Baseline Care Plan, dated 2/2/24, documents that R1 requires one-person physical assist for
locomotion on the unit. This form documents that R1 is cognitively impaired. R1's baseline care plan does
not have fall or safety interventions in place.
R1's Restorative/Rehabilitation Evaluation, dated 2/2/24, documents that R1 requires extensive assist of
one person for transfers.
R1's Progress Notes, dated 2/11/24 at 6:45am, documents that R1 was awake at 4:15am. R1 was assisted
to bed, but got out of bed. R1 was taken to the bathroom and fluids were offered, will continue to monitor.
R1's Progress Notes, dated 2/12/24, documents that at 8:30pm, V4 (Licensed Practical Nurse/LPN) kept
R1 by her side, due to R1 repeatedly trying to walk. R1 was given a stuffed animal to hold. V4 documented
that she came out of a room after giving a medication and heard R1 say AH! R1 was rubbing her left knee.
V4 documented that R1's knees were checked for injuries, but none were noted. R1 was asked if she could
move her legs, which she did. R1 was assisted up to her wheelchair. R1 progress notes document that R1
was rubbing above her knees. V6 (R1's Primary Care Physician) gave orders for hip and knee x-rays.
R1's Progress Notes, dated 2/13/24 at 12:45am, documents that R1 was crying out with facial grimacing
and grabbing her left leg and hip area. R1 was sent to the emergency room for suspected hip fracture. At
4:14am, V3 (Registered Nurse) documented that R1 was being admitted to the hospital for a left hip
fracture.
V9's (Certified Nursing Assistant) signed Witness Interview Form, dated 2/12/24, documents that Resident
(R1) frequently stands, self-transfers, walks around unsupervised. This form documents that R1 was one on
one with the nurse while passing medications.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
146116
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
03/13/2024
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
Level of Harm - Actual harm
Residents Affected - Few
On 3/13/24 at 10:30am, V7 (Registered Nurse/Minimum Data Set Nurse) stated that R1's base line care
plan did not have fall interventions put into place. V7 verified that R1 should have had a completed care
plan at the time of her fall.
On 3/13/24 at 2:20pm, V1 (Administrator) stated that R1 had a history of falls prior to admission to the
facility. V1 stated that the facility does not have the staff to do one on one care.
On 3/13/24 at 2:50pm, V4 (LPN) stated that R1 was anxious and kept trying to stand up. V4 stated that the
staff could not get their jobs done, so she took R1 with her during medication pass. V4 stated that she
entered a room to give medicine then heard a Ah. V4 stated she went to check on R1 and she was on the
floor. V4 stated that R1 was rubbing her knees but did not show signs or symptoms of pain. V4 verified that
R1 had adverse behaviors often. V4 verified that R1 was out of sight for only a minute and fell. V4 stated
that R1 did not get out of bed after returning from the hospital.
The facility's Care Plans policy, reviewed 03/13/24, documents that the resident care plan is initiated at the
time of admission. This form documents that the care plan will include the following information but not
limited: needs, concerns or problems identified during initial assessment of the resident.
The facility's Falls and Incident Reporting policy, modified 10/31/23, documents that a Fall risk Assessment
2.0 Form is to be completed as soon as possible and practicable, within 24-48 hours as practicable, when a
resident has sustained a fall. This form also documents that the resident's care plan is reviewed and revised
as indicated. Approaches will be implemented for ongoing evaluation of interventions will be done on a
resident individualized basis.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146116
If continuation sheet
Page 2 of 2
