Inspection·April 18, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify a resident's emergency contact representative regarding a fall incident. The failure to notify placed the resident at risk for compromised advocacy and potentially delayed medical decision making. This applies to 1 of 3 (R1) residents reviewed for notification of significant medical change. The findings include: The EMR (Electronic Medical Record) showed that R1, an [AGE] year-old with extensive diagnoses that included B cell lymphoma with metastasis to lymph nodes, lung cancer, intracerebral hemorrhage, atrial fibrillation, heart disease, hypertension, chronic obstructive pulmonary disease, peripheral vascular disease, venous insufficiency, left below knee amputee, chronic kidney disease, anemia, frontal temporal neuro cognitive disorder, urinary reflux, phantom limb syndrome with pain, anxiety, hyperlipidemia, osteoarthritis, Barrette's esophagus, benign prostate hypertrophy, carotid artery disease, hypomagnesemia, cholecystitis, acute kidney failure, mood disorder, malignant neoplasm of bone, non-Hodgkin's lymphoma, obesity, hyponatremia, psychophysical visual disturbances, falls, impaired gait, generalized weakness, and foot drop (right). R1 was admitted to the facility on [DATE] at 1:00 P.M. The EMR also revealed that R1 was hospitalized from [DATE] to April 4,2025 due to acute medical conditions that included UTI, urinary retention, toxic metabolic encephalopathy, and altered mental status. The hospital record dated March 29,2025 showed that R1 was hallucinating, secondary to UTI and TME (toxic metabolic encephalopathy, which was a condition with cerebral dysfunction manifested by altered consciousness, behavior changes and or seizures). R1 was treated with intravenous antibiotics and was admitted to the facility with continued oral antibiotics for UTI. The Physician notes entered by V3 (Physician) dated April 4,2025 at 11:08 A.M., showed that R1 was seen and examined by V3. The notes showed that R1 was alert and oriented x2. The notes also document that R1 could not answer what brought him to the facility. The Nurse Practitioner Notes (V4) dated April 4,2025 at 5:16 P.M., showed that R1 was alert and oriented x1-2. The notes showed that Assessment and Plan were muscle weakness, gait disorder, assist with ADL's (Activities of daily Living), PT/OT (Physical and Occupational therapy), and fall precautions. The nurse's notes dated April 6,2025 at 2:33 A.M. showed that V5 (Registered Nurse) had documented that R1 was found sitting on the floor next to the reclining chair in his room on April 5,2025 at 9:45 P.M. The notes also showed that R1 had hit his head, left side of the upper body and left hip. (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 4 Event ID: 145409 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 145409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Michaelsen Health Center 831 North Batavia Avenue Batavia, IL 60510 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)