Inspection·March 20, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a comprehensive Plan of Care with fall interventions for one (R3) of three residents reviewed for Care Plans in the sample of three. Findings include: R3's Diagnosis Sheet (current and on admission [DATE]) includes the following diagnoses: Displaced Spiral Right Humeral Shaft Fracture, Traumatic Subarachnoid Hemorrhage, Head Laceration, Anxiety, Depression and Urinary Tract Infection. The Facility Incident Fall Log dated for February 2024 documents two falls for R3. The first is documented on 2/14/24 and the second fall is documented on 2/19/24. R3's Fall Risk Evaluation dated 12/26/23 documents the following: Intermittent Confusion, 1-2 falls in past 3 months, Chair bound - requires restraints and assist with elimination, balance problem while standing, balance problem while walking, decreased muscular coordination, jerking or unstable when making turns, requires use of assistive devices (i.e., cane, wheelchair, walker, furniture, predisposing disease - 3 or more present. R3 is assessed as being at High Risk for Falls. R3's Plan of Care (current) appears to be a base line Care Plan from admission to the facility on [DATE]. R3's Care Plan documents the following on Falls: Focus Area - Risk for Falls. Goals - Resident will be free of falls. Interventions - assist resident with ambulation and transfer, utilizing therapy recommendations. Determine resident's ability to transfer. Evaluate fall risk on admission and PRN (as needed). If fall occurs alert provider. If fall occurs, initiate frequent neuro (neurological) and bleeding evaluation per facility protocol. If resident is a fall risk, initiate fall risk precautions. The Base Line Care Plan does not address R3's falls on 2/14/24 or 2/19/24 with interventions. On 3/20/24 at 1:40 pm, V2 Director of Nursing confirmed that R3's Care Plan was not up to date, and V10 Care Plan Coordinator needed to do a comprehensive plan of care on R3. V2 also confirmed that R3 had falls at home prior to admission and the facility was aware of R3 being a High Risk for Falls. 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: 146113 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 146113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenup Rehab and Nursing 300 North Marietta Street Greenup, IL 62428 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)