Inspection·December 8, 2023

F 0689 Level of Harm - Actual harm applied pressure. V10 said Emergency Medical Services (EMS) were called and R1 was transported to the hospital. V10 said if a resident does not propel themselves in the wheelchair they should have foot pedals on the wheelchair. V10 said R1 was propelling himself around the facility earlier in the day and was seen abruptly stopping his wheelchair with his feet and grabbing the hand rails. Residents Affected - Few On 12/7/23 at 11:37 AM, V4 (Physical Therapy Assistant) said she had evaluated R1. V4 said R1 was able to propel himself in his wheelchair. V4 said R1 sometimes was able to follow commands. V4 said if a resident was able to propel themselves, she would expect staff to remove the foot pedals from the wheelchair. V4 said if staff were propelling a resident she expected the foot pedals to be on the wheelchair. On 12/7/23 at 1:42 PM, V2 (Director of Nursing/ DON) said she had completed the investigation for R1's 11/18/23 fall. V2 said R1 was in the dining room blocking the exit and other residents were trying to get by. V2 said V3 (CNA) was assisting R1 out of the exit when R1 slammed his feet down and fell forward out of his wheelchair. V2 said she had reeducated all staff foot pedals were to be on the wheelchair with the resident's feet on the foot pedals if they are being propelled by staff. V2 said if R1 had foot pedals on his wheelchair on 11/18/23 the fall may not have happened. On 12/7/23 at 1:15 PM, V9 (Licensed Practical Nurse/ LPN) said she had cared for R1 once. V9 said R1 was oriented to self only and was not able to follow directions. R1's 11/18/23 at 6:00 PM Skilled Progress Note documented in part .Resident being assisted by CNA (V3) down the hall to the nurses station. Resident abruptly put his feet down which caused him to be propelled forward. Resident landed on the floor. Laceration above (left) eyebrow . Wash cloth administered to slow bleeding . 911 called . resident bound for (hospital) . R1's 11/18/23 at 10:30 PM Skilled Progress Note documented in part . Brain bleed found via CT (Computerized Tomography) scan. Resident being flown to a larger hospital . R1's 11/18/23 hospital record Physician Documentation documented in part . reports injury, a laceration, 5 cm (s), complex irregular, ragged, left eyebrow and left eyelid, pain, swelling, tenderness Resulted from a fall . impacting a hard surface . Pertinent positives: headache, injury. Severity of symptoms: At their worst the symptoms were severe, just prior to arrival . Wound Repair of 5cm (2.0 inch) subcutaneous laceration to left upper eyelid and left supraordital ridge. Profuse bleeding noted . Skin closed with 12 4-0 Ethilon using Simple sutures . (CT scan of head without contrast) . Impression: Small amount of interventricular hemorrhage (IVH). Recommend clinical correlation follow-up as clinically warranted .Diagnosis: Traumatic hemorrhage of cerebrum, unspecified, without loss of consciousness . laceration without foreign body of left eyelid and periocular area . R1 was then transferred to another hospital for a higher level of care. R1's 11/19/23 Neurosurgery Consult documented in part . recent admission to (hospital) 11/7/23 - 11/14/23 with (Intraventricular Hemorrhage) who presented to the hospital after sustaining a fall . The patient was seen in consultation . during his recent admission. Findings were non-surgical and patient was advised to hold his (aspirin) for 7 days . The patient returns to the hospital after sustaining a fall at his nursing home. He has a laceration to his forehead . CT head was completed redemonstrating blood in the right lateral ventricle slightly increased in size, thus the reason for neurosurgical consultation . R1's 11/19/23 History and Physical documented in part . reportedly had a fall at the nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146131 If continuation sheet Page 2 of 3 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 146131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cisne Rehabilitation and Health Care Center 107 North Watkins Street Cisne, IL 62823 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few facility where he resides. He did hit his head . He was previously on (aspirin) and Plavix, but has been on hold for 2-3 days, per report. Trauma evaluation . revealed IVH. He has a laceration to the left forehead, sutured . He was recently admitted to (hospital) after sustaining a fall and found to have IVH. He was evaluated by Neurosurgery, findings were found to be non surgical. He was to hold (aspirin) for 7 days. CT on 11/7/23 with no significant changes and trace amount of layering hemorrhage with the right lateral ventricle persists . On 12/8/23 at 11:04 AM, V6 (Neurosurgery Nurse Practitioner) said she had completed the consult for R1 on 11/19/23 after R1 ' s hospital admission. V6 said it would be very difficult to determine if the worsening of the intraventricular hemorrhage was caused by R1 ' s 11/18/23 fall or the use of blood thinners. R1's 11/18/23 Investigation Report for Falls documented in part . Root Cause Analysis: Resident's feet went under the (wheelchair) and it caused (R1) to fall out when (R1) put feet down suddenly causing chair to abruptly stop . What new intervention was implemented to prevent any further falls? (Wheelchair) to have foot pedals be placed and being utilized (at) all (times) while being propelled in (wheelchair) . The facility's 11/20/23 QAC Progress Notes documented in part . (Interdisciplinary team) discussed (R1) incident (with) significant injury. All documentation reviewed with root cause of fall determined. Care plan reviewed and updated with new interventions. (Administrator) and DON to continue internal investigation . Prior to this survey date, the facility took the following actions to correct the non-compliance: 1. Immediate Corrective Action: All nursing staff were educated by the DON/Director of Nurses that all residents that require a wheelchair and are being transported via facility staff should have wheelchair legs attached to the wheelchair during transport. 2. Systemic Changes to Ensure Compliance: All nursing staff were educated on ensuring that all residents have leg rest prior to facility transport, QAPI meeting was held on 11/20/23. 3. System Maintenance: DON or designee will do random checks daily for 3 week to ensure leg rest was attached prior to transport. 4. Other Residents with the Potential to be Affected: All residents have the potential to be affected by the alleged deficient practice. The facility's Daily Wheelchair Audit Form documented daily checks for footrests from 11/20/23 through 12/7/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146131 If continuation sheet Page 3 of 3