Health inspection·September 11, 2025

F 0580 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure complete and timely physician notification following a resident accident and subsequent change in condition for one of three residents (R1) reviewed for notification of change out of a sample list of three. This failure resulted in R1 experiencing excruciating pain to her right hand due to a delay in notifying the physician and ultimately leading to a diagnosis of a fracture.Findings include:The facility's Physician Notification Policy revised 11/5/2022 documents a facility will immediately inform the resident; consult with the resident's physician; and notify, of a significant change in condition in a resident's physical, mental, or psychosocial status or a need to alter treatment significantly.The facility's Change in Condition Procedure revised 9/21/2022 documents a change in condition requires notification of Medical Doctor of change and resident assessment information. R1's Nurse Progress Note dated 8/12/25 documents R1, who utilizes a wheelchair was on a supervised outing with facility staff. While navigating a grassy area, R1 slid forward out of her wheelchair, landing on her knees and both hands. Staff immediately assessed the resident on-site. R1 voiced she was fine and attempted to reposition herself independently. Staff assisted her back into the wheelchair without issue and returned R1 to the facility. R1 was assessed upon return to facility and Physician, Director of Nursing (DON), and Administrator were notified, and an intervention was initiated for foot supports to be added to R1's wheelchair to prevent future sliding incidents.R1's Medical Diagnoses revealed R1 has Myasthenia Gravis and Cerebellar Ataxia, both of which affect muscle strength, coordination, and mobility.R1's Minimum Data Set (MDS) dated [DATE] documents that R1 is cognitively intact and requires substantial/maximal assistance with standing and transfers. R1's Nurse Progress Note dated 8/12/25 at 3:50 PM, documents R1 reported minimal pain in the right hand following a fall earlier that day. R1's right hand had mild edema and scant discoloration observed on the 3rd, 4th, and 5th fingers. Ice was applied to the right hand. R1 stated It does not hurt really unless she moves her fingers.R1's Nurse Progress Note dated 8/13/25 at 12:30 AM documents R1 was complaining of discomfort right hand, right hand is very swollen and bruised, unable to grip with hand. R1's right great toe is painful and bruised. Ice offered for hand, resident declined, the pressure causes discomfort. R1 states she injured her hand on outing in wheelchair.R1's Nurse Progress Note dated 8/13/25 at 10:30 AM documents R1 was up in her recliner chair with right lower extremity (RLE) elevated due to swelling on the top of right foot area from the previous incident on 8/12/25. Bruising continues to R1's right great toe between toe and top of right foot. R1's right hand remains swollen with bruising. Will continue to monitor.R1's Nurse Progress Note dated 8/13/25 at 11:30 AM documents Ordered through portable X-Ray two view Xray of right hand due to moderate swelling and moderate bruising with pain, per V9 (Medical Director).R1's Nurse Progress Note dated 8/14/25 at 10:45 AM documents R1's X-ray results of right hand reveal prominent displaced fractures involving the base of the proximal Page 1 of 3 146057 146057 09/11/2025 Monmouth Rehab and Nursing 117 South I Street Monmouth, IL 61462

F 0580 Level of Harm - Actual harm Residents Affected - Few phalanges of the third through fifth digits.On 9/10/2025 at 8:50 AM, R1 was seated in a wheelchair and had a hard cast on her right wrist. R1 was pleasant and alert during the interview. When asked about the injury, R1 stated, (R1) was with (V3/Activity Director) on my way to the store. (V3) was pushing me in my wheelchair, and we hit a curb or something on the ground, and (R1) fell out into the grass and broke her hand. R1 stated they had her foot in a boot as well because of her toe, but it's doing better. R1 stated she normally wears foot pedals outside of facility but forgot them that day. R1 stated if she had foot pedals on the chair she would not have fallen out. R1 further stated that she immediately felt excruciating pain in her right hand shortly after her fall and that she made the staff aware of the pain as soon as staff arrived to help R1 up from the ground. On 9/10/25 at 9:54 AM, V3 (Activity Director) stated that the facility regularly takes residents on outings to a local store, located one block from the facility. V3 reported, We take side streets when we walk because it's less busy. There's a three-four-foot patch of grass off the sidewalk. V3 explained that during the outing on 8/12/2025, she remained with R1 while other residents and staff returned to the facility. V3 stated, I told her hold on, I'll put my bags down and help you. V3 reported that R1 self-propels using her arms and feet, and that as V3 attempted to assist R1 through the grassy area, which was uneven, then it happened so fast that R1's wheelchair's front wheels were in the grass and the rear wheels remained on concrete. V3 stated, (R1) slipped out of wheelchair going forward and I think R1 put her feet down to break the fall and was on her knees, put her hands down on the ground to break her fall. (R1) then rolled over in the grass. V3 noted that R1 was not wearing foot pedals at the time, adding, She never does wear them. V3 acknowledged, It was swollen very quickly. I should've done things differently-I probably should have had foot pedals on, or pulled her backwards, or taken her another way. V3 contacted the facility immediately, and two Certified Nursing Assistants (CNAs) were sent to assist, as V3 is not a CNA or nurse.On 9/10/25 at 10:30 AM, V4 (Licensed Practical Nurse/LPN) stated that she was made aware of the fall by V2 (Director of Nursing) and was unsure who assisted R1 at the scene. V4 reported, I don't remember any CNAs leaving the floor to go help. V4 stated that R1 did complain of pain during her assessment upon returning to the facility. However, V2 directed staff to wait a day or two before determining whether R1 needed an X-ray or further evaluation. V4 also stated she was told that V3 was pushing R1 in her wheelchair when they hit something, causing R1 to fall forward. V4 added, I was told that (R1) stopped her fall using her hands on the ground.On 9/10/25 at 12:00 PM, V2 (DON) stated that on 8/12/2025, she received a call from V3 (Activity Director) reporting that R1 had slid out of her wheelchair while outside the facility at a local store and was on the ground. V2 stated she sent two CNAs to assist because V3 was not certified to lift or transfer residents. Upon R1's return to the facility, V2 assisted V4 (LPN) with the assessment. V2 reported that R1 did not complain of pain, swelling, or bruising at that time, so they decided to monitor her condition. V2 stated that on 8/13/2025 at 12:30 AM, V5 documented increased pain, swelling, and discoloration to R1's hand. V2 acknowledged that V5 should have reported this change in condition to the physician. V2 also stated that V6 (RN) documented continued pain and swelling on 8/13/25 without notifying the physician.On 9/10/25 at 1:05 PM, V8 (CNA) stated on 8/12/2025, she and V7 (CNA) were passing lunch trays when V2 (DON) informed them that R1 had fallen outside of a local store and needed assistance. V8 reported that when they arrived, R1 was sitting on the ground. V7 and V8 used a gait belt to assist R1 back into her wheelchair. V8 stated, (R1's) right hand was very swollen, and (R1) was complaining that it hurt. V8 observed that R1's hand became more swollen and bruised over the next few hours. V8 stated she provided care for R1 again on 08/13/2025, and R1 continued to complain of pain in her right hand and foot. V8 reported that she notified V4 (LPN), and that 146057 Page 2 of 3 146057 09/11/2025 Monmouth Rehab and Nursing 117 South I Street Monmouth, IL 61462

F 0580 Level of Harm - Actual harm Residents Affected - Few V2 responded, (R1) hand will be fine-it's probably just a sprain. V8 stated that V4 appeared upset and felt R1 needed an X-ray. V8 further stated we are often told by management to not report things.On 9/10/25 at 1:30 PM, V7 (CNA) stated that when she and V8 arrived at the scene on 8/12/2025, R1 was sitting on the ground with her legs extended and hands on the ground. V7 reported that R1 stated her hand was very sore and asked staff to be careful with it. V7 observed that R1's hand was swollen, bruised, and stated, Her hand was hurting her very bad. V7 stated that she and V8 notified a nurse but could not recall which nurse was informed. V7 also stated she was not aware of R1 refusing to wear foot pedals, noting, Sometimes she wears them and sometimes she doesn't.On 9/10/25 at 8:30 AM, V9 (Medical Director) stated he remembers receiving the call on 8/12/25 regarding R1's fall. V9 stated he does not remember exactly what was said to him at that time, but if it was conveyed to him that R1 was in a lot of pain or had swelling V9 would have sent R1 to the emergency room to be evaluated. V9 stated when he saw R1 the next day he ordered an Xray. V9 stated he expects to be notified any time a resident has a condition change or increased pain. V9 stated he does not recall the facility calling him with updates on R1's change of condition. 146057 Page 3 of 3