Health inspection·May 7, 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. Based on interview and record review the facility failed to ensure a resident's bed was in the low position and the mat was on the floor to prevent injury from falling out of bed. This applies to 1 of 3 residents (R3) reviewed for safety in the sample of 3. The findings include: R3's Incident Report dated 3/22/25 at 6:50AM states, Resident was lying on the floor next to the bed on his left side with his right arm underneath him. Blood noted to hand and when assessed it was from laceration to right eyebrow. When resident asked if he fell out of bed he nodded and said yes and was pointing at something he was reaching for a drink. The facility Final Investigation Report dated 3/22/25 states, Facility completed its investigation and it was determined thru multiple interviews with staff and resident that resident became impulsive and impatient, did not request for staff assistance when attempting to retrieve an item, subsequently fell and sustained an open area to the right eyebrow requiring sutures . R3's Progress Notes dated 3/22/25 at 7:37 AM state, Resident was laying on floor of room next to his bed. (Mechanical Lift) sling was on bed as someone had put it under him and bed was left in high position. Bleeding noted to right eyebrow. Resident sent to ER (Emergency Room). and at 10:39 AM Returned from ER. CT (CAT scan) of cervical spine and head without contrast. X- Ray of right hip and pelvis. Sutures to right eyebrow and bruising noted upon return. R3's Progress Notes dated 3/22/25 at 2:48 PM state, Resident assisted to bed and complains of right leg pain. Previous X- Ray done at ER with no findings. PRN (As needed) pain pill given and explained to resident he is going to be sore from falling from bed to floor. R3's Progress Notes dated 3/23/25 at 5:53 AM state, Stayed in bed tonight. Sutures intact above right blackened eye. Complains of pain to eye area, right knee and left side, pain pills bring relief and sleepiness. On 5/6/25 at 2:25PM V8 (Night shift CNA- Certified Nursing Assistant) stated, I left about 6 AM, I heard about the fall later. We often get him up on night shift and sometimes we get him ready but if I don't have anyone to help me because you need two staff to use the (Mechanical Lift) then I will just leave him in the bed. I don't think I would have left the bed in the high position. I don't recall doing that. On 5/6/25 at 3:30 PM V9 (Day Shift CNA) stated, (R3) is a midnight get up so I didn't even go in Page 1 of 2 145989 145989 05/07/2025 Parker Nursing & Rehab Center 516 West Frech Street Streator, IL 61364

F 0689 Level of Harm - Minimal harm or potential for actual harm there when I got there. I was down the hall getting someone else up and I had to go find help because she is a (Mechanical Lift) transfer. I went down the hall and I saw him lying on the floor next to his bed. His bed was kind of high up and there was no mat on the floor. He is supposed to have a mat. I saw he was bleeding so I ran to get the nurse. The (Mechanical lift) sling was lying on the bed like it had been under him. He said he was reaching for his pop when he fell off the bed. Residents Affected - Few On 5/7/25 at 10:10 AM V7 (RN- Registered Nurse) stated, The CNA (V9) came to the nurse's station and said (R3) was on the floor. I went to the room and he was on the floor. The bed was in the high position and there was no mat on the floor. It was like the night shift CNA got the (Mechanical Lift) sling under him and got ready to get him up and then never went back to get him up. He had a cut above his right eye and I sent him to the ER. He got sutures and had some bruising when he came back but I didn't notice anything else different about him. He is very difficult to understand. He points to things when he has pain but that is about all. He is dependent for care and uses a (Mechanical Lift) for transfers. R3's EMR (Electronic Medical Record) shows his current care plan as: (V3) is at Risk for Falls as evidenced by the following risk factors and potential contributing Diagnosis: CVA (Cerebrovascular Accident) with Right Hemi, COPD (Chronic Obstructive Pulmonary Disease), Atrial Fibrillation, CHF (Congestive Heart Failure), Epilepsy, Neuralgia and Neuritis, Cervicalgia, BPH (Benign Prostatic Hypertrophy), Depression, Anxiety,and HTN (Hypertension). The Interventions include: 5/7/2023--Place my bed in the lowest position while I'm in bed and 7/18/2022 Apply Floor Mats to the side of my bed. 145989 Page 2 of 2