Health inspection·August 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 Based on interview and record review, the facility failed to develop an effective plan with interventions to prevent or reduce the risk of falling for a resident diagnosed with Dementia, wandering behaviors and identify as a high fall risk with balance problems while standing. This affected one of three residents reviewed for falls and fall prevention. This failure resulted in R2 having eight falls, seven of which were unwitnessed and one fall resulting in right periorbital soft tissue swelling and right scalp hematoma with contusion of face and scalp. Findings Include: R2 was diagnosed with Dementia, lack of coordination and need for assistance with personal care. R2's Fall risk observation dated 4/10/24 documents: disoriented times three (person, place, and time) and balance problems while standing, high risk. R2's Care Plan dated 4/12/24 documents: R2 presents with wandering behaviors. Wandering with or without a purpose. R2 was risk for falling related to Dementia, weakness, and history of falls. On 8/10/24 at 2:07pm, V2 (restorative nurse) stated, R2 had a fall in the dining room on 4/19/24. V2 stated, she watched the facility video and saw R2 fall face forward while tying her shoestrings. On 8/11/24 at 3:20pm, V7 (nurse) stated, she was getting off duty for on 4/19/24 when she was notified of R2's swelling around eye. V7 stated, she does not recall what happened. R2 takes baby steps. R2 has a shuffled gait. Any time, R2 attempts to get up, R2 is trying to toilet self. R2 is Japanese. R2 can answer yes or no questions. R2 can ambulate by herself but it's not safe. Event report dated 4/19/24 documents: Resident (R2) noted with swelling/bruising to right brow area from unknown origin. Fall risk observation dated 4/19/24 documents: balance problems while walking. Nursing note dated 4/19/2024 documents: Observed mild swelling to resident's upper right brow with tinge redness above brow and cheek area. R2 will be admitted for observation unwitnessed fall. Hospital paperwork dated 4/19/24 documents: Syncope and Collapse. Nursing note dated 4/22/24 documents: Post fall observation for right eye orbital swellings and contusion. Nurse Practitioner note dated 4/23/2024 documents: R2 presented to emergency department due to a fall. R2 was noted with contusion of face and scalp. CT (computed tomography) of sinus facial bones showed right periorbital soft tissue swelling and right scalp hematoma. On 8/10/24 at 1:57pm, V4 (nurse supervisor) stated, R2 was seen on the floor at breakfast time in the dining room on 4/24/24. R2 was kept in the dining room for monitoring. R2 wheelchair was locked (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: 145879 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 145879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tri-State Village Nrsg & Rhb 2500 East 175th Street Lansing, IL 60438 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)