Inspection·December 5, 2023

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 provide individualized fall interventions and provide safe access for communication/response to resident's requests for care. This failure affects one resident (R5) of five residents reviewed for fall interventions in the sample of five. Findings include: The facility's Fall Prevention Program/Protocol dated Revised 2/1/23, documents based on previous evaluations and current data, staff will identify interventions related to resident's specific risks to prevent resident from falling; new admissions will be reviewed for fall history and interventions put in place prior to admission to the facility; and rounds will be completed at least daily to ensure fall intervention remain in place. R5's Nursing Progress Notes dated 11/15/23 at 7:20 PM, documents R5 arrived to the facility by ambulance from the hospital, oriented to self only, resident up walking in halls, gait unsteady. This same progress note documents significant physical therapist findings for R5 which include: weakness, decreased endurance, decreased strength, decreased cognition, impaired balance and impaired gait that leads to impaired ability to perform functional transfers and ambulation. R5's undated Face Sheet documents R5's diagnoses as: Metabolic Encephalopathy, Alcoholic Cirrhosis of Liver with Ascites, Unspecified Dementia, unspecified severity, without Behavioral disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety, [NAME] Matter Disease, unspecified, Fracture of one rib, left side, subsequent encounter for fracture with routine healing, Emphysema, unspecified, Moderate protein-calorie Malnutrition, Pulmonary Fibrosis, unspecified. R5's Minimum Data Set (MDS) dated [DATE], documents R5 is not cognitively intact with inattention and disorganized thinking. R5's Post Acute Care Transition Document dated 11/15/23, documents Lovenox (anticoagulant injections) through 11/15/23 and R5 needs Fall Precautions at the Skilled Nursing Facility. R5's Care Plan dated 11/29/23, documents R5 has impaired cognitive function/dementia related to Dementia and impaired decision making. This same care plan documents R5 is at risk for falls related to cognitive impairment, dementia, unsteady gait, pain, weakness, history of falls prior to admission. On 11/29/23 at 11:35 AM, R5 lying in bed. When asked R5 question R5 would say okay and then repeated the question, being unable to communicate relevant responses. Call light at the end of R5's bed (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: 145862 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 145862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hilltop Skilled Nsg & Rehab 910 West Polk Street Charleston, IL 61920 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)