Inspection·April 7, 2023

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 adequately supervise a cognitively impaired resident and maintain a bed alarm in proper working condition. This failure resulted in R1 sustaining Thoracic-10 and Lumbar-2 (spinal) fractures. The facility also failed to utilize the Physician Ordered full mechanical lift to provide a safe transfer for a R3, resulting in a fall. R1 and R3 are two of three residents reviewed for falls on the sample list of six. Findings include: 1. R1's Physician Order Sheet (POS) dated 4/7/23 documents the following diagnoses: Altered Mental Status, Long Term Current Use of Aspirin, Repeated Falls, Unspecified Dementia Unspecified Severity, Osteoporosis and Anxiety. The same POS documents: Bed sensor pad on bed at HS (Bedtime) d/t (due to) poor sitting balance in bed/awareness, weakness, unsteady gait, inability to transfer self. Check every shift to ensure sensor pad is working. Start date 01/18/2021. R1's Minimum Data Set (MDS) dated [DATE] documents the following: R1 has a Brief Interview for Mental Status score of 2 out of 15 indicating severe cognitive impairment. The same MDS documents R1 requires physical staff assistance with transfers, ambulation and toileting. R1's Nurses Note dated 12/24/2022 at 03:32 am documents the following: Note Text: Roommate (unidentified) alerted staff of resident (R1) fall (,) resident on floor in bathroom (,) on right side (.) residents alarm did not sound (.) no injuries present (,) neuros (neurological assessment) and vitals initiated (,) resident (R1) assisted to bed (,) alarm replaced and working (.) resident reminded to use call light. R1's Health Status Note dated 12/28/2022 at 10:15 am documents the following: Note Text: Resident (R1) ambulated to shower room with staff assist-writer called to shower room per CNA (Certified Nursing Assistant) (unidentified)-noted purple/yellow fading bruising across mid chest to top of breasts-resident denies discomfort. Had last fall 12/24/22 which was unwitnessed. DON (V2/Director of Nursing) notified. R1's Nurses Note dated 12/29/2022 at 11:54 am documents the following: Note Text: Follow up on C-Xray (Chest X-ray). (V20/Physician) notified of new compression fracture of T10 and L2 (thoracic and lumbar region of the spine). (V20) would like the family (V27) POA to give a go-ahead for the treatment. (V20) states fosamax (Fosamax) 70 mg (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: 146049 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 146049 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Iroquois Resident Home, The 200 Fairman Avenue Watseka, IL 60970 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)