Health inspection·March 15, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the Facility failed to ensure progressive fall interventions were in place for 1 of 3 residents (R1) reviewed for accidents and hazards in the sample of 6. Findings include: R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including heart failure, type 2 diabetes mellitus, unspecified dementia, restlessness and agitation, and history of falling. R1's Minimum Data Set (MDS) dated [DATE] documented R1 was severely cognitively impaired, ambulated via wheelchair, was dependent with transfer, and required substantial/maximal assistance with toileting, bathing, dressing, oral hygiene and rolling from side to side. R1's Undated Care Plan documents R1 is at risk for falls and injuries related to medications and medical factors, including heart failure, type 2 diabetes mellitus, and history of falling. R1's Fall Risk assessment dated [DATE] documented R1 was at high risk of falls. R1's 5/4/22 Fall Report documents R1 was found sitting in the middle of the floor in his room. R1 reported he was trying to get a newspaper off the floor and accidentally knocked over his water pitcher and slipped. There were no injuries. The Root Cause was determined to be R1 reaching for an item that fell onto the floor and knocking over a beverage, causing him to slip. The intervention was providing R1 with a reacher to prevent the need to bend for items out of reach. R1 was also educated on using the reacher. R1's Care Plan Intervention dated 5/4/22 documents, Reacher provided to assist and prevent the need for bending to obtain out of reach items. R1's 11/11/23 Fall Report documents R1 was found on the floor in his room next to his bed with the alarm sounding. R1 was crawling on the floor toward his wheelchair, stating he was hungry and was going to breakfast. There were no injuries. The Root Cause was determined to be R1 trying to get up and get snacks. The intervention was staff to provide snacks at bedside. R1's Care Plan Intervention dated 11/11/23 documents, Provide Snacks at bedside. On 3/13/24 at 11:21 AM, R1 was not in his room. There were no visible snacks in his room or on top (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 2 Event ID: 145508 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 145508 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Health Care Center 1450 26th Street Highland, IL 62249 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)