Health inspection·September 25, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on interview and record review the facility failed to implement/update interventions following an accident/fall for two residents (R1, R3) of three residents reviewed for care plans in a sample list of three residents. Findings include: The facility's policy Fall Prevention revised 11/10/18 states Immediately after any resident fall the unit nurse will assess the resident and provide any care and treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. The unit nurse will place documentation of the circumstances of the fall in the nurse's notes or on an AIMS for wellness form along with any new interventions deemed to be appropriate at the time. 1. R1's Progress Note dated 8/25/2023 at 10:13PM documents CNA (V3, Certified Nurse's Aide) getting (R1) ready to transfer and was putting recliner down. (R1's) legs were in between recliner and where it closes, (V3) didn't notice (R1's) legs were hanging off due to blanket covering (R1's) legs. Resident stated 'Oww' and (V3) noted legs were hanging off sideways where recliner closes. (V3) moved blanket and noted resident right leg bleeding. (V3) notified Nurse (V7, Licensed Practical Nurse LPN). (V7) went in and assessed (R1's) right leg and large skin tear/laceration down front of right shin to almost (R1's) ankle. Bleeding profusely. Applied pressure and (abdominal gauze) with tape to area to try and stop bleeding. NP (Nurse Practitioner) notified at 9:06PM and gave order to Send to Emergency Room. Notified daughter 9:20PM. 911 called at 9:30PM. Director of Nursing /Administrator notified at 9:40PM. R1's Progress Note dated 8/25/2023 at 11:50PM and R1's Progress Note dated 9/12/2023 1:22PM go on to document (R1) received 13 sutures and (Nylon wound closure strips) at the emergency room to close the wound. R1's Care Plan printed 9/25/23 at 11:40AM does not document any resident centered interventions were initiated following this incident to prevent reoccurrence. 2. R3's Progress Note dated 8/23/2023 at 1:04PM documents: (R3) was ambulating with wife without a gait belt, wife was walking in front of him, leaving the dining room table. (R3) stated he blacked out. (R3) then fell back into the nurse's cart, knocked the water pitcher over, hit the trash can on the way down. (R3) moves all extremities, no rotation/shortening noted, complains of pain only back of head, (R3) has a knot on the back of the head left midline, (R3's) back is red. (mechanically lifted) resident to bed. Doctor notified. order to send out. emergency room called. Wife was here for (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: 145466 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 145466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Lakes Extended Care 310 Eads Avenue Paris, IL 61944 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)