Health inspection·November 20, 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 provide a safe transfer for 1 of 3 residents (R1) reviewed for transfers in the sample of 10. This failure resulted in R1 being left unattended as staff left the room and R1 fell out of the bed and sustained an Intracranial hemorrhage (head injury).Findings include:R1's Physician Order Sheet (POS) for November 2025 documents a diagnosis of unspecified sequelae of unspecified cerebrovascular disease, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side; dementia in other diseases classified elsewhere; unspecified severity without behavioral disturbances, psychotic disturbance, and insomnia. R1's Minimum Data Set (MDS) dated [DATE] document R1 was moderately impaired for cognition for activities of daily living. Under Roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed- R1 was documented as Dependent. Dependent documents the Helper does ALL of the effort. Resident does none of the effort to complete the activity, or the assistance of 2 or more helpers is required for the resident to complete the activity.R1's Care Plan with the date initiated of 11/19/2021 documents, Fall Risk: (R1) is at risk for falls due to confusion, gait/balance problems. He has history of syncope, seizure disorder, stroke with right-sided weakness, history of falls. He has weakness/unsteady, incontinent of bowel/bladder. He leans in his wheelchair when he is tired.R1's Fall Risk assessment dated [DATE] documents R1 was high risk for falls.R1's Health Status Note dated 11/8/2025 at 9:45 PM, Note Text: CNA (Certified Nursing Assistant) reported she had resident on bed and resident had extra large bm (bowel movement), she walked away to get toilet paper from bathroom and observed resident falling off bed, resident did not become unconscious, alert and responding appropriately with clear speech, CNA states resident was on right side and rolled himself over to his left side, states he is not in pain, no abnormalities noted to head, skin intact, resident remained in position this writer first observed him in, resident contracted and has limited ability to move limbs, order to send resident for evaluation to rule out injury, echo transport notified, residents POA (Power of Attorney) updated on incident per phone call and agrees to bed hold policy at this time.R1's Health Status Note dated 11/9/2025 at 1:09 PM, Note Text: called ER (Emergency Room) for follow up, resident being transferred, call placed to POA (Power of Attorney) and he is aware of transfer, and dx (diagnosis of) right frontal lobe hemorrhage.On 11/13/2025 at 2:05 PM, V12, CNA stated, I am familiar with (R1). He is not able to turn himself. I was performing incontinent care on him, and he had a large BM and I went to get toilet paper. (R2) usually does not move but when I left his bed he rolled over and fell off the bed. I have been trained and I never should have left him unattended, and I feel bad. I know they sent him out to the hospital. We are not supposed to ever leave resident unattended while providing incontinence care. On 11/13/2025 at 3:15 PM, V14, CNA stated If we are providing incontinent care, we are never to leave the resident even for a minute unless we put the bed down all the way, put resident back on their back and give (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: 146059 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 146059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove Health & Rehab Ctr, The 873 Grove Street Jacksonville, IL 62650 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)