Health inspection·December 11, 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 observations, interviews, and record review the facility fail to revise and implement care plan interventions to prevent falls and provide safety for a resident identified as risks for falls. This applies to 1 (R47) of 3 residents reviewed for safety and supervision in the sample of 20.The findings include:R47 was admitted to the facility on [DATE], with multiple diagnosis including metabolic encephalopathy, acute cholecystitis, diabetes, lack of coordination, difficulty walking, cognitive communication deficit, muscle wasting, spinal stenosis, Parkinson's, history of falls and altered mental status. A nursing Progress note dated November 29, 2025, shows R47 was agitated following lunch and constantly moving via wheelchair through the halls. R47 was observed by staff bending over trying to fix attached footrest. R47 needed constant reminders to sit back in wheelchair to avoid falling. R47 bent forward in chair and was caught by nurse prior to falling to the ground. Per nurse R47 needed to be monitored at nurses' station and required constant queuing, reminding, and distractions for safety. One to one care was suggested. Progress notes from September 2025 to December 2025 show frequent episodes of agitation, restlessness, and behaviors that could have or resulted in a fall.On December 08, 2025, at 11:31AM, R47 was sitting in dining room in a high back wheelchair with four other residents including R13. There were no staff members present in dining room. R13 was sitting in a wheelchair nearby R47. R13 said that she watches over R47 when he is in the dining room because he gets up from his wheelchair and falls frequently. R47 was sitting at the edge of his wheelchair bending over and picking at the floor. R47 stood up from the wheelchair and attempted to lift his right leg over the right foot pedal. R13 called out to the nurses who were standing near a medication cart in the hall for help. R13 said that she often calls for help when this happens. R13 said there is not enough staff to sit with him, so she watches him. R47 attempted to stand and walk away from his chair at 11:39AM, 11:44AM, and 11:50AM. Each time R47 was redirected by R13 without the supervision of staff. On December 09, 2025, at 8:53AM, R47 was observed sitting in the dining room without supervision. R47 was sitting on edge of the wheelchair picking at the floor. Two puddles of clear liquid were noted on the floor behind the center of the wheelchair. There was also a puddle of light brown liquid noted on the floor near the right side of the wheelchair. There were no CNA's (Certified Nursing Assistants/CNA) or nurses in the nearby corridors or at the nurses' station. On December 10, 2025, at 9:55AM, R47 was observed propelling via wheelchair using his feet and holding on to objects along the way. R47's feet were placed under the footrest during this time. R47 stopped at the nurses' station. While sitting on the edge of the wheelchair, R47 bent over and began to pick at the foot pedals. R47 then continued to propel himself in his wheelchair using his feet. There were no nurses or CNAs at the nurses' station or in the corridors at this time. On December 10, 2025, at 10:08AM V16 (CNA) said that she was assigned to R47, and that staff observes them when they can, however this is hard to do as there are only two CNAs on the unit. V16 said that R47 had one to one care Page 1 of 2 145623 145623 12/11/2025 Arcadia Care Morris 1095 Twilight Drive Morris, IL 60450

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few initially when he admitted to the facility, but that has since stopped as they no longer have the additional staff. V16 said that R47 does not engage in activities often and stays on the unit most of the time. On December 08, 2025, at 1:45PM, V19 (Family Member) said that R47 has had too many falls to count since being admitted to facility in September. R47's most recent fall was on December 07, 2025. V19 said she was informed that R47 would be kept at the nurses' station for supervision. V19 also said she is unaware of any additional interventions that have been put in place to prevent falls. R47's care plan dated September 29, 2025, shows R47 has impaired cognitive function and requires total assistance from staff for toileting, bed mobility, bathing, and transferring. R47's current fall care plan show's he experienced falls on September 29, November 14, November 19, November 26, December 04, and December 07 and does not include interventions for supervision/monitoring, fall risk behaviors, or personalized preventative interventions. An Active care plan dated September 29, 2025, shows R47 has impaired cognitive function and requires total assistance from staff for toileting, bed mobility, bathing, and transferring. R47's current fall care plan show's he experienced falls on September 29, November 14, November 19, November 26, December 04, and December 07 and does not include interventions for supervision/monitoring, fall risk behaviors, or personalized preventative interventions. The care plan interventions were not revised after fall incidents.On December 10, 2025, at 10:30AM, V20 (Care Plan Coordinator) said that she is responsible for putting fall interventions on the resident's care plans. V20 said if a resident continues to fall, it indicates that current interventions are not working. Interventions are adjusted as needed. On December 10, 2025, at 11:30AM, V2 (DON) said she is responsible for the Fall Prevention Program and that after a fall, immediate interventions are put in place by the nurse. The fall and interventions are then reviewed by the interdisciplinary team and adjustments to interventions are made if needed. V2 said that residents can be placed on safety monitoring if necessary. V2 said that she considers R47 to be a high fall risk and that he is not currently on safety monitoring. V2 said that R47 has never been on safety monitoring and that R47 should be monitored. V2 said she is unsure of when interventions are reviewed in care plan because V20 is responsible for care planning. On December 10, 2025, at 3:40PM, V1(Administrator) said that if a resident is agitated, the expectation is for staff to monitor, determine the source of the agitation, and intervene right away. The facility's Fall Prevention Program policy dated May 2025 shows the purpose is to ensure safety of all residents in the facility when possible. The program includes measures to determine individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision. The guidelines state that the care plan should incorporate identification of all risk/issues, addresses each fall, ensure interventions are changed with each fall as appropriate, and ensure preventative measures are put in place. The standards show that safety monitoring beyond two-hour checks can be put in place and can be as frequent as fifteen-to-thirty-minute checks with documentation records to validate observations. Safety monitoring is discontinued only when the risk factors requiring monitoring is no longer evident as determined by the supervising nurse or interdisciplinary care team. 145623 Page 2 of 2