Inspection·December 11, 2024

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, record review and interview the facility failed to notify the doctor and obtain wound treatment orders for one resident (R1) and failed to investigate, monitor, and implement new fall interventions for two residents (R1, R2) of three residents reviewed for accidents and injuries in a total sample of three. Findings include: A facility policy titled Incident and Accidents - Illinois last revised 05/2022 documents, The Incident/Accident Report is completed for all unexplained bruises or abrasions, all accidents or incidents where there is injury or the potential to result in injury, allegations of theft and abuse registered by residents, visitors or other, and resident-to resident altercations. A section titled Procedure defines an accident as, any happening, not consistent with the routine operation of the facility that results in bodily injury other than abuse. An incident/accident report will be completed for all serious accidents or incidents of residents, all unusual occurrences and any condition resulting from an accident requiring first aid, physician visit, or transfer to another health care facility. This policy documents 1. An incident/accident report is to be completed by a RN (Registered Nurse) or LPN (Licensed Practical Nurse) and is to include: a. Date and time of incident/accident; b. Full written statement and possible cause of incident, physical assessment, injuries noted, vital signs, treatment rendered, and notification of appropriate parties. 2. An RN or LPN must notify the following if an actual injury occurs: a. Physician; b. Legal representative or interested family member within 24 hours. The policy continues, 4. Documentation in nurses' notes is to include: a. A description of the occurrence, the extent of injury (if any), the assessment of the resident, vital signs, treatment rendered, and parties notified; b. A minimum of seventy-two (72) hours (longer, if indicated of documentation per day on resident status after the incident (vital signs, mental and physical state, follow-up, tests, procedures, and findings are to be documented. 5. All incident/accident reports are reviewed, signed and investigated by: a. The Administrator; and b. The Director of Nursing or the Assistant Director of Nursing and c. The Medical Director). Routine fall risk audits are to be completed no less than quarterly. A facility policy titled Pressure Injury and Skin Condition Assessment last revised 01/2018 documents that a skin condition assessment and pressure ulcer assessment will be completed at the time of admission/readmission and that residents identified will have a weekly skin assessment by a licensed nurse. This policy also documents At the earliest sign of a pressure injury or other skin problem, the resident, legal representative, and attending physician will be notified. The initial observation of the ulcer or skin breakdown will also be described in the nursing progress notes. (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 4 Event ID: 145886 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 145886 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Aledo 304 S.W. 12th Street Aledo, IL 61231 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)