Inspection·April 21, 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 interview and record review the facility failed to provide one staff assistance to prevent a fall for one (R1) of three residents reviewed for accidents in the sample list of five. Findings include: R1's Facility Census documents R1 was admitted to the facility on [DATE] and has the following medical diagnosis, Malignant Neoplasm of Endometrium, Chronic Pain Syndrome, Weakness, Overactive Bladder, Age-Related Osteoporosis, GERD, Encounter for Palliative Care and Anemia. R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview for Mental Status (BIMS) score 8, moderate cognitive impairment, needs substantial/maximum assistance with Activities of Daily Living. R1's Care Plan dated 8/17/23 documents R1 is at risk for falls due to limited physical mobility related to chronic pain syndrome and Osteoarthritis. Interventions. Transfers: R1 transfers with one staff assist/gait belt and rolling walker. R1's Health Status Note dated 4/1/25 at 7:33pm documents V4 Certified Nursing Assistant notified V3 Registered Nurse (RN) that R1 was on the floor. Found R1 lying on right side with head toward toilet and facing shower. Right arm was behind R1. Knees bent and toward the shower and feet toward bathroom door. [NAME] in front of toilet. R1 assessed by V3 and V5 Nurse Manager. R1 able to move all extremities with some pain to the right leg. R1 was turned onto R1's back and three assisted to wheelchair without difficulty. Vital Signs - Temperature-98.2, Pulse-94, Respirations-18, Blood Pressure-177/125. Neuros started and within normal limits (WNL). V4 reported that R1 was assisted off toilet and then R1 was walking toward the door when R1 fell. R1 did not remember how it happened. V6 Physician notified at 11:30pm and recommended that resident go to Emergency Department (ED). V7 R1's Power of Attorney/Daughter POA (refused) did not want to send resident to ED. R1 had multiple injuries. 1-Right side of head 6.0-centimeter x 4-centimeter hematoma, 2- Right shoulder 8.0-centimeter x 4.0-centimeter bruise, 3-Right elbow 1.5-centimeter x 0.1-centimeter skin tear, 4-Right hand 0.5-centimeter x 0.1 centimeter skin tear and 1.0-centimeter x 1.0-centimeter bruise, 5- Right lower leg 3.0-centimeter x 2.0-centimeter skin tear. V4 Certified Nursing Assistant (CNA) witness statement dated 4/1/25 at 11:00am documents at 10:45am V4 took R1 to the restroom, used walker for transfer, when R1 was done, used the rail to get off seat and wiped R1, pulled R1's brief up and pants up. V4 was standing in front of R1's walker waiting for R1. R1 grabbed R1's walker. V4 walked to the bathroom door, stood and waited for R1. R1 was (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: 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 04/21/2025 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)