Health inspection·June 13, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident was assessed following an alleged fall for 1 of 3 residents (R1) reviewed for fall assessments in the sample of 3. Residents Affected - Few The findings include: R1's admission record shows she was admitted to the facility on [DATE] with multiple diagnoses including severe dementia without behavioral disturbance, anxiety and depression. R1's 4/18/25 Resident Assessment and Care Screening documents R1 to have moderate cognitive impairment. On 6/13/25 at 9:50 AM, R1 was observed lying in bed, alert and confused. She was unable to answer questions with any clear answers. She was wearing a hospital gown, and had an indwelling urinary catheter. Her room was located on the dementia unit. The facility's 5/9/25 final incident investigation report documents on 4/29/25 R1 was observed sitting on the floor in her room leaning against her bed. R1 stated she had fallen, and was unable to recall how she fell. The report shows V4 and V5 Certified Nursing Assistants (CNA's) reported to V6 Licensed Practical Nurse (LPN) R1 had fallen out of bed. The report shows V6 sent R1 to the emergency room for evaluation. On 6/13/25 at 12:15 PM, V4 said she was working on the west wing when V5 came out of the dementia unit asking for help with R1, because she was on the floor. V4 said V5 notified V6 of the incident at same time. She said V6 asked what had happened, and then told them to get R1 up and put her back into bed. V6 did not go to assess R1 at that time. V4 said R1 was moved from the floor to the bed, but could not recall what time this had occurred. Then just before the end of the shift at 6:00 AM, V6 said R1 was being sent out to the emergency room. The ED (Emergency Department) record for R1 shows the date and time of service to be 4/29/25 at 7:18 AM. The chief complaint was a fall, and R1 had complaints of mid back pain and right rib pain. The discharge assessment and clinical impression shows closed fractures of the 8th and 9th ribs on the right side. R1's 4/29/25 Nursing Progress Notes show she was transported back from the emergency department (ED) at 11:16 AM, and was received by V12 LPN. The progress notes do not show evidence of a fall incident, resident assessment, or documentation of notifications or what time R1 was sent out to the ED. Page 1 of 2 145446 145446 06/13/2025 Marigold Rehabilitation and Health Care Center 275 East Carl Sandburg Drive Galesburg, IL 61401

F 0684 Level of Harm - Minimal harm or potential for actual harm On 6/13/25 at 11:30 AM, V12 LPN said on the morning of 4/29/25, she relieved V6 and received in report R1 had been sent out for evaluation due to behaviors. She was not given report of any fall. V12 said when she reviewed R1's notes, there was nothing charted. She said V6 should have charted the fall, and an assessment with vital signs. She should have noted if there was any head injury and range of motion. V12 said she found out about the fall when the emergency room called to let her know R1 had fractured ribs. Residents Affected - Few On 6/13/25 at 10:37 AM, V3 Assistant Director of Nursing (ADON) said when a resident has a fall, the nurse should immediately assess the resident for any injury or possibility of injury and if the resident needs to be sent out to the ED. She said the nurse should document in the progress notes the assessment, what occurred, and what immediate interventions should be put in place to prevent further falls. She said the importance of the documentation is for staff to know what is going on with the residents. The facility's 4/29/25 policy for Post Fall Procedure documents Post Fall: After a resident fall, they must be stabilized by the nursing staff. A fall risk evaluation must be completed by the charge nurse. A detailed progress note must be documented in the resident's record, including root cause analysis, resident provider notification, resident representative notification, details of injury if present, new intervention, pertinent statement, and any other details surrounding the resident fall. 145446 Page 2 of 2