Health inspection·May 10, 2024

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a safe transfer for 1 of 3 residents (R2) reviewed for falls in the sample of 13. This failure resulted in R2 sustaining a large, abrasion/laceration on her right calf while being transferring without the use of a gait belt and needing wound care. Findings include: R2's Physician Order Sheet for May, 2024 documents a diagnosis of abnormal weight loss, hereditary hemochromatosis, unspecified severe protein calorie malnutrition, alcoholic hepatitis without ascites, chronic obstructive pulmonary disease, disorder of iron metabolism, irritable bowel syndrome with diarrhea, body mass index 19.9 or less, adult, arthropathic psoriasis, monoclonal gammopathy, ankylosis, spondylitis lumbar region. R2's Minimum Data Set (MDS) dated [DATE] documents R2 is cognitively intact for decision making of activities of daily living. I use a wheelchair and a walker and have no impairment on my upper and/or lower extremities. R2's Resident Profile Page dated 4/5/2024 documents, I have a goal of increasing my independence. I am at risk for falls. I require assistance with transfers and ambulation. My goal is to reduce the risk factors that contribute to my fall risk and to minimize the risk of injury related to my fall throughout this review. My goal is to discharge home independently with home health. I am five foot seven and weigh 87 pounds. I have a risk for skin breakdown. I have a risk for skin breakdown. I received skin tear to right lower leg from transfer. Treatment orders in place and improvement noted at discharge. R2's Physician Note SBAR (Situation, Background, Assessment and Recommendation) dated 4/1/2024 at 10:00 AM, documents, I was called to patients' room at approximately 9:30 AM, because she was yelling in pain. The CNA informed me that her skin on her right leg got bumped during transfer. DON assisted me down to her room and patient's right calf had skin tear 7 x 4 cm (centimeters) in size. CNA informed me that she was transferring her from the wheelchair to the bed and the patient started to slide out of her wheelchair and she was able to put her on the bed before she slid on the floor. Patient stated she felt as if her leg hit the footboard and blood was spotted there. I assisted the DON with wrapping the patient's leg to control drainage. Patient is lying in bed, call light in reach. Incident report made. R2's Wound Assessment Report dated 4/2/2024 documents wound length 9.9 x 5 (width) x 0.2 cm3 (depth) for right calf. L (length) x w (width) = 49.5. The facility photograph dated 4/2/2024 was reviewed (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 3 Event ID: 145121 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 145121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alton Memorial Rehab & Therapy 1251 College Avenue Alton, IL 62002 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)