Inspection·June 15, 2023

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 observation, interview, and record review the facility failed to implement appropriate fall interventions for one of three residents (R1) reviewed for falls in a sample of three. This failure resulted in R1 obtaining bilateral black eyes, fracturing her right nasal bone, and knocking out two natural teeth. Findings include: The facility's Fall Prevention Program, revised 1/21, documents to provide ongoing risk reducing interventions. This form also documents to provide ongoing evaluation of resident response to intervention. On 6/14/23 at 10:30am, R1 was in her wheelchair in activities. R1 had black yellowish bruising on her bilateral cheek bones. R1 also had a healing laceration under her chin. At 1:40pm, R1 stated that she does not remember what happened the night of the fall but knew that it hurt. R1's Fall Risk Assessment, dated 6/10/23, documents a score of 12, indicating R1 is at risk for falls. R1's current care plan documents that R1 requires the assist of one for toileting needs and transfers or ambulating. R1's Progress Notes, dated 6/10/23 at 8:15pm, R1 was observed laying on the floor in the prone position. R1's hands were curled to her side, legs together with her pants around her ankles, there was a small amount of blood on the floor at R1's head. V3, Registered Nurse, called out R1's name, with no response. V3 cradled R1's head and rolled her onto her right side. R1 had a facial injury with R1's lower mouth actively bleeding. R1's partial denture found on floor. Resident's eyes were open, pupils equal in size. R1 then responded when her name was called out. With concern for her safety, R1 was not moved again. R1 stated she thought her right hip was broken. Upon ambulance arrival, R1 stated she had pain in her back, neck, hip, and face. R1 was placed on a sheet and slid on the floor to make room for gurney. R1 was lifted off the floor and placed on the gurney. R1's emergency room notes, dated 6/10/23, documents that R1 presented with pain, laceration to face and puncture through her chin. R1 broke her dentures and possibly other teeth. R1's assessment documents that R1's upper dentures were broken and removed in three pieces. R1's upper lip has a skin abrasion, and her lower lip is diffusely swollen. R1 has a 1.5cm (Centimeter) laceration on the lower aspect of the external lower lip, near her chin. R1's Computed Tomography scan showed a chronic right nasal bone fracture. On 6/14/23 at 3:10pm, V6 CNA, (Certified Nursing Assistant), stated that R1 was standing in the (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: 145039 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 145039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Healthcare of Peoria 5600 Glen Elm Drive Peoria, IL 61614 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)