Inspection·December 13, 2025

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 perform safe turning and repositioning during care for 1 of 3 residents (R1) reviewed for falls in the sample of 3. Findings include:On 9/19/2025 at 10:02 AM, R1 was sitting in his wheelchair watching the television. R1's bed has low air mattress on it.R1's Minimum Data Set (MDS) dated [DATE] document R1 was cognitively intact for decision making of activities of daily living. R1 has impairments of one side on both his upper and lower extremities. R1 uses a wheelchair and needs substantial assistance with most activities of daily living. R1's Care Plan: start date of 11/15/2024 documents, Problem: Resident is at risk for falls and injuries r/t weakness, Parkinson's, left hip dislocation. 8/19/2025 fall from bed.On 9/18/2025 at 9:53 AM, R1 stated he remembered when he fell. He had just had a shower and the staff had put him on the bed but there was only one staff member, it was a male staff, and he rolled him because he was putting some cream on him and the staff was grabbing on to the strap under him because he is a (mechanical lift) and there are no bars on the bed except near the head and the staff rolled him too far and kept telling him to roll, which he did, and then he fell off the bed onto the floor.R1's Progress Notes dated 8/19/2025 at 10:45 AM, This nurse was called to room. Resident was turning to side of bed to get cream put on buttocks. Resident slid/fell off the side of the bed. Witnessed. No hitting of the head. fell on Lt (left) knee, an abrasion is visible. Resident is currently taking blood thinners. Sending to hospital for further checkup. R1's Safety Event Fall Report dated 8/19/2025 at 10:51 AM, Resident has low air mattress, resident was wet from shower. Made it slippery for resident to be able to roll to side. Resident slipped out of bed.On 9/18/2025 at 9:54 AM, V4, Licensed Practical Nurse (LPN) stated, (R1's) certified nursing assistant (V8) had just given him a shower and he likes special lotion and the (V8) was rolling him on his side to put lotion on him and he has an air mattress, and he was alone and when he rolled over, he fell off the bed. He is a (mechanical lift).On 9/18/2025 at 10:03 AM, V8, Certified Nursing Assistant (CNA) sated, I remember when (R1) fell I was giving care to him. I had just finished a shower with him and took him back to his room. He is a (mechanical lift), and I was putting cream on his butt and when I turned him over he turned over too far and he slipped off of the bed and onto the floor. Normally, when providing care, I was supposed to have another staff member with me. It was just me that time and we were so busy I provided the care by myself. I did not put anything down on the bed and he fell.On 9/18/2025 at 10:10 AM, V2, Director of Nursing stated, when a resident has a low air mattress because those things are tricky, I expect staff to put a blanket underneath them before laying them down, so they do not fall out. Staff failed to put the blanket down, and with the shower, and lotion he was slippery and slid off the air mattress. (R1) was sent out to the hospital but he did not have any fractures or serious injuries.The Facility Fall Policy with a revision date of July 2014 documents, It is the policy of (facility) to decrease the numbers of falls in the facility. The fall program is designed to facilitate (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: 145601 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 145601 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviston Countryside Manor 450 West 1st Street Aviston, IL 62216 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)