Health inspection·September 24, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm 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 was positioned safely in bed to prevent a fall for 1 of 3 residents (R2) reviewed for safety and supervision in the sample of 5. Residents Affected - Few The findings include: The Nurse's Note dated 9/20/24 at 8:30 PM showed, Resident (R2) was found at 7:30 PM by CNA (Certified Nursing Assistant) staff at the time this writer arrived resident vitals were assessed and stable. Client told staff she wanted to get her cranberry juice and slid out of her bed. No signs of distress or discomfort shown by client. Client expressed her bottom was hurting but she did not have any other pain. This writer reached out to clients POA with direct phone call and advised client would have to be sent out for further evaluation per standard protocol due to client being on blood thinner medication. On 9/21/24 at 1:00 AM staff was contacted by the hospital nurse and was notified that the resident was being admitted for a subarachnoid bleed. On 9/21/24 at 7:07 PM, Nurse to nurse report given by hospital nurse to this writer/nurse - the hospital performed a head computerized tomography scan that showed trace bilateral subarachnoid bleed. R2 given vitamin K in the emergency room. Resident returned to unit (at facility) by ambulance transport. The Hospital Record for R2 dated 9/21/24 showed the CT of the head for R2 was redone and, the previously mentioned subarachnoid hemorrhage is likely artifactual. On 9/24/24 at 1:19 PM, R2 was sitting in a wheelchair in the activity room. R2 was leaning forward in her wheelchair and was sleepy. On 9/24/24 at 1:47 PM, V11 CNA stated, V13 (CNA from the agency) had R2. V11 stated V13 sat R2 up on the side of her bed and had the tray table in front of her so she could eat. V11 stated when R2 was done eating she had pushed the tray table away from her. V11 stated R2 was sitting up on the side of her bed for over an hour. V11 stated R2 did not have good sitting balance because she sits forward. V11 stated when R2 is in her wheelchair she leans forward, and you can tell her to sit back, and she will. V11 stated R2 will fall asleep sitting up. R2 is usually put to bed right after lunch and dinner. V11 stated V13 wasn't doing anything; he told V13 to get up and go to the dining room. V11 stated they don't like to leave residents in their rooms for meals because they can't be monitored, and anything can happen. V11 stated R2 slid off the bed onto the floor. V11 stated the nurse came and had to assess to make sure the resident was okay. R2 said she didn't hit her head. It just looked like she slid out onto her butt onto the floor. R2 has poor balance when sitting and gets tired easily. V13 had her sitting up on the side of the bed too long. V11 stated they used a mechanical lift to get her up off the floor and into bed. (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: 146101 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 146101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willows Health Center 4054 Albright Lane Rockford, IL 61103 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)