Inspection·November 12, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few documented V5 certified nursing assistant (CNA) and V6 (CNA) put R2 in her bed from 1:45-1:50 PM. At 1:50 PM, V3 (CNA) walked down the hall and saw R2 lying on her left side on the floor with a puddle of blood under her head, 911 was called and EMS (emergency medical services) arrived at 2:00 PM. All responsible parties were notified. On [DATE] the facility was informed that R2 had expired at the hospital on [DATE]. On [DATE] at 2:16 PM, V1 (Administrator) and V2 (Director of nursing/DON) presented video footage of R2's hallway prior to, during and after her fall on [DATE]. The facility's video footage documented the following: on [DATE] at 12:45 PM, V5 (CNA) wheeled R2 into her room. At 12:47 PM, V6 entered R2's room also. At 12:53 PM, V5 exited R2's room and seconds later V6 (CNA) exited. At 1:10 PM, V10 (Activities Director) entered R2's room and exited at 1:11 PM. At 1:43 PM, V3 (CNA) walked by R2's room and then entered it; V1 stated this was when R2 was found after falling.R2's Emergency Department Records dated [DATE] documented R2's assessment/plan included: fall, scalp laceration, depressed skull fracture, orbital fracture, subdural hematoma, subarachnoid hematoma, intraparenchymal hematoma of brain, maxillary fracture and temporal bone fracture. R2's Intensive Care Hospital Note dated [DATE] documented, admitted with severe TBI (Traumatic Brain Injury) and altered mental status superimposed on chronic neurocognitive disorder. Concern for impending uncal herniation syndrome. After discussion with family, transitioned to comfort-oriented care.On [DATE] at 11:27 AM, V8 (ER Nurse) stated R2 presented to her emergency department with an abrasion to her forehead, her nose was bleeding, both eyes swollen and purple from bruising. V8 stated the facility claimed R2 was found lying on the ground in her blood from falling out of her bed but the paramedics said her bed was in the lowest position. V8 stated the extent of R2's injuries does not match up with falling from a short distance. V8 stated R2 was flown to a larger hospital to get more care because they couldn't close up the laceration and she had a brain bleed, skull fracture and orbital fracture. On [DATE] at 8:25 AM, V3 (CNA) stated she saw R2 on the floor the day she fell. V3 stated she was walking by her room and just noticed her in a puddle of blood. V3 stated it looked like R2 was trying to get out of bed without assistance which was common for her to do. V3 stated R2 had alarms on her chair and bed but they weren't going off when she fell. V3 stated R2 did have a fall mat and when she is in her wheelchair a lap belt is used. V3 stated R2's bed was in low position, and she was a high fall risk. V3 stated stars are placed by resident names outside their doors to indicate they are high fall risk also.On [DATE] at 8:55 AM, R2's room did not have a star next to her name.On [DATE] at 8:58 AM, V4 (Registered Nurse/RN) stated R2 was mostly confused, sometimes combative and was able to scoot herself around in her wheelchair. V4 stated R2 would sometimes use her call light or yell out if she needed something. V4 stated R2 was a high fall risk, and she could not get herself out of bed safely. V4 stated R2 had a belt to wear in her wheelchair too.On [DATE] at 10:39 AM, V2 (DON) stated when R2 fell, she heard the CNA yelling and when she got to the room R2 was on the floor. V2 stated she got down on the floor and assessed R2 who was responding to her appropriately and admitted she fell. V2 stated R2 was on her left side with half her body on the fall mat, the upper half on the floor. V2 stated the bed alarm was still on R2's bed but R2 would turn it off. V2 stated they had the fall mat and bed in low position care planned for her falls. V2 stated the bed alarm was not going off at the time.On [DATE] at 11:37 AM, V5 (CNA) stated she took care of R2 the day she fell, and she was acting like her normal self. V5 stated R2 was getting tired, so she took her back to her room to lay down and cleaned her up too. V5 stated she put R2's bed alarm in place and she had her fall mat. V5 stated before she left R2's room, she had her eyes closed and looked like she was falling asleep. V5 stated 3-5 minutes later she heard another CNA yelling after finding R2 on the ground. V5 stated R2 liked to get up without assist and she'd fallen in the hallway once prior from her wheelchair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145465 If continuation sheet Page 2 of 4 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 145465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Nsg & Rehab Center 1001 South State Street Jerseyville, IL 62052 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few V5 stated after her fall in the wheelchair a belt was added for R2 to wear, and she always had a wheelchair alarm. V5 stated she would take R2 on walks or keep her in front of the nurse's station for distraction and supervision. V5 stated R2 would let them know typically if she needed something. V5 stated after R2 fell she saw blood on the floor and her face.On [DATE] at 12:03 PM, V6 (CNA) while in R2's room, stated after lunch R2 was laid down right away, she was cleaned and in bed with her alarm and fall mat in place along with her call light in reach. V6 stated it was 2-3 minutes after she'd left the room before she heard screaming. V6 stated when she responded to R2's room after she fell, R2 was not on the fall mat. V6 stated R2 must have wiggled herself to the foot of her bed to get out of it. V6 stated R2's bed was in the lowest position. V6 stated R2's bed legs were approximately a foot elevated from the floor at the lowest. R2's bed was approximately 12 inches above the ground, not including her mattress and the floor was tile. V6 stated R2 was completely out of range of the fall mat from where she fell. V6 stated R2 doesn't remember she can't walk by herself and was forgetful. V6 stated when R2 fell, the bed alarm was not going off, but it was in place. V6 stated they would keep R2 up at the nurse's station for more supervision because she was constantly trying to get up. V6 stated R2's hall is the heaviest hall with multiple fall risk residents on it.On [DATE] at 1:18 PM, V7 (Paramedic) stated he responded to R2's fall. V7 stated when he entered R2's room, her bed was closest to the door and to the right side with the foot of her bed to the right of the doorway. V7 stated R2 was lying on her left side and had a lot of blood on her, she was moaning and had purposeful movements with her eyes open but was not speaking. V7 stated he thinks R2's bed was in a lower setting and couldn't remember if there was a fall mat or not, but no alarms were going off when he arrived. V7 stated R2 was actively bleeding, and her hair was saturated with blood. V7 stated they had to use a blanket to pick her up off the floor. On [DATE] at 1:42 PM, V5 (CNA) stated R2 did not have her television on [DATE] after she laid her down for her nap, she was too tired.On [DATE] at 1:43 PM, V6 (CNA) stated R2 didn't have tv on after lunch on [DATE], she was tired.On [DATE] at 12:33 PM, V3 (CNA) stated R2 did not have the tv on in her room on [DATE] when she found her, there was a light on, and she was wearing non-slip socks.On [DATE] at 1:44 PM, V9 (Care Plan Coordinator/RN) stated she created R2's care plan putting in an original plan for falls and updating it with every fall after. V9 stated R2 had a self-release belt as a fall intervention that should have been added at the same time her bed and chair alarms were, but she couldn't see it was actually added. V9 stated she and V2 follow up on the effectiveness of the interventions. V9 stated R2 knew how to turn the bed/chair alarms off, she would grab the box and turn it off. V9 stated the belt was typically, effective for R2 and while in bed having the tv on was important for distraction because there weren't any eyes on her in there and the belt was only for her wheelchair. V9 stated R2 would be placed by the nurse's station, along with things to keep her distracted like snacks. V9 stated when R2 fell, half of her body was on the fall mat and the upper half was on the floor. V9 stated R2 also had a side rail on her bed to help her with rolling.On [DATE] at 12:36 PM, V10 (Activities Director) stated she had gone into R2's room to pass out activities information but she appeared to be sleeping having her eyes closed on [DATE]. V10 stated she couldn't recall if R2's roommate was in the room at the time or if the tv was on or not. V10 stated R2 liked to color and would attend activities a lot. V10 stated she wasn't sure if R2 could turn her alarms off or not. V10 stated R2 was initially irritable when she admitted and didn't like to be alone but eventually, she was content with being in her wheelchair. V10 stated R2 had been spending too much time in bed.On [DATE] at 10:10 AM, V2 (DON) stated R2 would turn her bed alarm off, she did that a lot. V2 stated we didn't have this documented, but we were doing 15-minute checks on R2 while she was ever in bed, she was the only one we had to do (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145465 If continuation sheet Page 3 of 4 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 145465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Nsg & Rehab Center 1001 South State Street Jerseyville, IL 62052 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete that on, otherwise we would have her more supervised and up at the nurse's station. V2 stated R2's only major health concern was that she didn't have fingers or toes, so we wanted to keep her safe. V2 stated the bed alarm was not an effective intervention for R2, the alarm was only effective when used in her wheelchair. V2 stated in agreement that R2 already had use of bed and chair alarms in place prior to her fall [DATE], it would not have been a new intervention. V2 stated in agreement that R2's bed had already been put in low position with a fall mat in place prior to her fall on [DATE] and that it wasn't added to her care plan interventions until after the fall. V2 stated maybe they could have put the alarm box inside R2's bedside table to keep her from turning it off.On [DATE] at 11:50 AM, V11 (Medical Director) stated his main concern for R2 was preventing falls. V11 stated he hadn't seen R2 yet but was scheduled to see her this month. V11 stated in his clinical expertise, a TSH (thyrotropin) level of 34 and having hypothyroidism would not have an effect on the risk of falls. V11 stated he would expect staff to be following the fall risk care plan interventions if they were able to do so. V11 stated he would expect interventions to be progressive and resident centered, if R2 was able to turn off the alarm, he would expect the facility to attempt to prevent her from being able to do so by hiding it. V11 stated if the fall risk interventions were not being followed and they were previously working, it could pose a higher risk for R2 to fall.On [DATE] at 2:18 PM, V2 (DON) stated the facility did not have an alarm policy but they did have guidelines for Personal Alarms. The Personal Alarms guidelines (undated) documented bed exit alarms are often used as an intervention for fall reduction programs, but they are not always used effectively. It continued to document it is important that when placing an alarm to consider many reports describe patients deliberately deactivating their alarms and may not be appropriate.The facility's Falls Management Policy dated [DATE] documented it is the policy of the facility to assess and manage resident falls through prevention, investigation, and implementation and evaluation of interventions. Event ID: Facility ID: 145465 If continuation sheet Page 4 of 4