Health inspection·May 5, 2025

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 prevent an injury by failing to ensure a bed was in a low position for one (R1) of three residents reviewed for falls on the sample list of three. This failure resulted in R1 sustaining a laceration to the right forearm, a hematoma, and spinal fracture which required emergency medical treatment. Findings include: The facility's Managing Falls and Fall Risk Policy with a revision date of 12/2021 documents that staff will identify and implement relevant interventions to try to minimize serious consequences of falling. R1's Care Plan initiated on 9/3/2019 documents that R1 was at risk for injury related to mobility status. This Care Plan documents that R1 has a history of skin tears, bruises, and a history of falls. This Care Plan documents an intervention for the bed to be in the lowest, most appropriate position when resident is resting in bed. R1's Incident report dated 4/14/2025 documents R1 was found on the floor next to the bed at 10:40 PM by V9, Certified Nurse's Assistant. This report documents R1 had large laceration to the right forearm and a large hematoma (bruised knot) to the right forehead. R1 was sent to the emergency room for evaluation. This report documents V6, Licensed Practical Nurse found that R1's bed was not in the low position stated in the Care Plan. R1's emergency room summary dated 4/15/2025 documents that R1 had a fall out of bed that resulted in broken bones to R1's spine and a contusion on R1's forehead. This report documents R1 required pain medication (Norco) to relieve R1's pain from the injuries. On 5/5/2025 at 1:37 PM, V9 stated he was doing his 10 PM resident checks and walked into R1's room and saw her on the floor and immediately went and got the nurse. V9 stated R1's bed was in the high position when he found R1 on the floor which isn't facility protocol. V9 stated that he was 6 foot tall, and the bed was at his hip level. V9 stated he went and got V6 for help. On 5/5/2025 at 11:37 AM, V6 stated on 4/14/25 around 10:40 PM, V9 came and told me that R1 was lying on the floor. V6 stated when she walked into the room, R1 was laying on the floor next to the bed. V6 stated that she noticed R1 had a pretty good-sized goose egg on her head from falling out of bed. The goose egg was the size of a fist. V6 stated she called 911 and kept R1 on the floor in the same position. V6 stated that the bed was not in the low position and that it was up higher than she (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: 145883 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 145883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piatt County Nursing Home 1111 N State St Monticello, IL 61856 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)