Health inspection·December 11, 2024

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to supervise a resident after providing the resident with a hot beverage. This failure affects one (R504) is one of three residents reviewed for supervision in the sample of 3. This failure resulted in R504 spilling hot liquid on R504's lap sustaining redness and 6 blistered areas to R504's bilateral upper extremities requiring subsequent treatment for 3days. Findings Include: R504's Facility Census documents R504 was admitted to the facility on [DATE] and has the following medical diagnoses: Congestive Heart Failure, Reflux Disease, Alzheimer ' s Disease, Dementia, Difficulty in Walking, Age-Related Physical Debility, Muscle Wasting and Atrophy, Fall, Muscle Weakness, Hypertension, , Cognitive Communication Deficit, Repeated Falls, Personal History of Mental Behavioral Disorders, [NAME] ' s Syndrome, Cerebral Infarction, Pulmonary Embolism without Acute Cor Pulmonal and Personal History of Transient Ischemic Attack (TIA) and Cerebral Infarction. R504's Minimum Data Set (MDS) dated [DATE] documents R504's Brief Interview for Mental Status (BIMS) score 5, severe cognitive impairment and eating supervision or touching assistance. R504's Care Plan dated 10/10/24 documents R504 is at risk for altered nutrition due to diagnosis of Dementia, Hypertension, Dehydration, Congestive Heart Failure, Reflux disease. R504 am a regular diet, R504 self-feed's unassisted in assisted dining room with supervision, R504 weight is at high end of desired body mass index (BMI) range 60 cubic centime (cc) med pass supplement three times a day (TID). Intervention: R504 self-feed 's with queuing in the assisted dining room. R504's Health Status Note dated 11/30/24 at 3:41pm documents R504 was in dining room when V8 Registered Nurse was notified at 11:15am that the R504 was attempting to remove R504's lid off R504's hot tea and spilled hot tea on R504 self. Upon arriving to dining room R504 upper thighs pant legs were wet. Removed R504 immediately to R504's room and placed R504 on the toilet as V8 removed R504's clothing immediately. V10 Certified Nursing Assistant (CNA) arrived, and this nurse requested V10 remain with R504 while V8 retrieved wound supplies. R504 had no blisters present at this time. Applied Zinc oxide skin protectant to reddened region and notified on call V21 Nurse Practitioner at 11:35am and awaiting return call, at 11:39am family notified of incident with tea, 11:55am V1 Administrator notified of incident. Ice pack wrapped applied on for 10 minutes off 20 minutes. Fluid filled blisters appeared (x6) (Left lateral W 4.5 centimeters x L 1.0 centimeters,) (Left medial thigh W L 4.0 centimeters x W 6.0 centimeters), (Left inner medial L 1.0 centimeters x W 2.5 centimeters), (left inner thigh lateral aspect L 1.0 centimeters x3.8 centimeters), ( Left inner thigh lateral posterior aspect W 1.2 centimeters x L 1.0 centimeters), (Right leg blister inner lateral L W 3 centimeters x 1 (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 3 Event ID: 145708 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 145708 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Health 2304 C R 3000 N Gifford, IL 61847 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)