La Salle County Nursing Home

In the surveyor’s words

From the most serious findings on record at La Salle County Nursing Home, in the surveyor’s own words.

• Actual harm, isolatedF692Aug 15, 2024

  Based on observation, interview, and record review the facility failed to identify a severe weight loss and put interventions in place for one (R33) of one resident reviewed for nutrition in the sample of 27. This failure resulted in R33 having a continued severe weight loss of 10.2% in one month and 12.9% loss in six months. Findings include: The facility's Resident Weight policy, dated 7/1/18, documents Any significant weight discrepancy from the previous weight is to be investigated at that time to rule out errors in weighing the resident (scale errors, incorrect procedure.) The nurse will report significant weight gains or losses to the physician and to the dietary department. […]

• Actual harm, isolatedF689Mar 13, 2024

  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. […]

• Actual harm, isolatedF689Jul 5, 2023

  Based on observation, interview and record review the facility failed to ensure one resident (R3) was safe to operate a motorized wheelchair of three residents reviewed for accidents. This failure resulted in R3 sustaining a foot laceration requiring stitches at the hospital. Findings include: Facility policy/Falls and Incident Reporting documents: Each incident involving a resident shall be documented on a standard Incident Report Form. All incidents are treated in that same manner. Incidents are identified as any event or occurrence out of the ordinary process of care including such events, but not limited to, the following: 2. […]

• Actual harm, isolatedF689Aug 6, 2021

  Based on observation, interview, and record review, the facility failed to ensure bed brakes were locked while providing care, failed to ensure two staff assist for bed mobility, dressing for two residents, and failed to provide the appropriate size bed for safe bed mobility for two (R1, R2) of three residents reviewed for falls. This failure resulted in R1 sustaining a scalp laceration with sutures, shoulder, and scalp contusions and an 18-centimeter skin tear. Findings include: R1 was admitted to the facility on [DATE] and has current diagnoses that include Lung/Brain Cancer, [CONDITION(S)] status post Stroke and Obesity. […]

• No harm, potential for more than minimal, widespreadF812Aug 15, 2024

  Based on observation, interview, and record review the facility failed to date opened food items, use items within the opened date timeframe, and failed to implement the cleaning schedule of equipment. This has the potential to affect all 59 residents residing in the facility. Findings include: The facility's Food Storage: Cold Foods, revised 04/2018, documents that all foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. The facility's Equipment policy, revised 09/2017, documents that all food service equipment will be clean, sanitary, and in proper working order. This form also documents that all food contact equipment will be cleaned and sanitized after every use. […]