Health inspection·April 14, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review the facility failed to report an injury of unknown origin to the Administrator and the State Agency for one resident (R1) of three residents reviewed for abuse in a sample list of five residents. Findings include: The facility Abuse Prevention Program revised 11/28/16 states The nursing staff is additionally responsible for reporting on a facility incident report the appearance of bruises, lacerations, other abnormalities, or injuries of unknown origin as they occur. Upon report of such occurrences, the Nursing Supervisor is responsible for assessing the resident, reviewing the documentation and reporting to the administrator or designee. This policy also documents, Final Investigation Report: The investigator will report the conclusions of the investigation in writing to the administrator or designee within five working days of the reported incident. The final investigation report shall contain the following: Name, age, diagnoses, and mental status of the resident allegedly abused or neglected; The original allegation (note day, time, location, the specific allegation, by whom, witnesses to the occurrence, circumstances surrounding the occurrence, and any noted injuries;facts determined during the investigation, review of medical record and interview of witnesses); conclusion of the investigation based on known facts; If there is a police report attach the police report; Attach a summary of all interviews conducted with names, addresses, phone numbers and willingness to testify of all witnesses. This report also states, A written report shall be sent to the Department of Public Health. R1's diagnoses list printed 4/8/25 at 2:52 PM includes the following diagnoses: Encephalopathy, Fall, Urinary Tract Infection, Cardiac Arrhythmia, Anticoagulant Use, Congestive Heart Failure, Hypertension, Hyperlipidemia, Mild Dementia with Anxiety, Protein Calorie Malnutrition, Weakness, and Pressure Ulcers of both heels Stage II. R1's AIM for Wellness note dated 3/11/25 at 12:15AM documents R1 has bruising to R1's right buttock measuring 4 centimeters in length and 2 centimeters in width. The Note documents R1 appears to have sustained an injury that was unwitnessed or is of unknown origin. Event was first noted on 03/11/2025 at 12:15 AM. Evaluation of the resident and event occurred on or about 03/11/2025 12:15 AM. Just prior to/at the time of the event (R1) appears to have been sleeping in bed. R1 is unable to relate details. Witness to the event includes: No one. On 4/9/25 at 2:00PM V1, Administrator stated Quite frankly I didn't do a complete report for the bruise because I wasn't aware the bruise had been found. I also did not report to the (State Agency) because I wasn't aware of the injury of unknown origin. If I had been aware I would have initiated an immediate investigation and reported to the (State Agency). 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: 145631 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 145631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Newman Rehab & Health Care Ctr 418 South Memorial Park Drive Newman, IL 61942 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)