Inspection·November 14, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to provide supervision for 1 of 5 residents (R2) reviewed for dining assistance in the sample of 9. Findings include: On 11/14/23 at 8:05 AM, R2 is in her bed with the head of bed up at 45 degrees. R2 has her breakfast tray in front of her. She has scrambled eggs in between her biscuit halves for a sandwich. She has eaten only a small amount. She has spilled her coffee cup onto the tray. She has a small glass of orange juice and a bowl of oatmeal which she has not touched. Her silverware was still wrapped in the paper napkin which is soaked with coffee which she spilled. R2 has no staff with her in the room. On 11/14/23 at 10:50 AM, V5, Certified Nurse Aide, stated that R2 has a very poor appetite. R2 needs a little assistance with meals because she has poor eyesight. Sometimes she is alert and other times confused. On 11/14/23 at 1:35 PM, V3, Assistant Director of Nurses, stated that R2 should be supervised while she is eating. On 11/14/23 at 2:00 PM, V3, stated that the facility does not have a policy on dining assistance. R2's admission Profile, print date of 11/14/23, documents that R2 was admitted on [DATE] and has a diagnosis of Palliative Care. R2's November 2023 Physician Orders documents, Admit to Hospice dx, (diagnosis), aspiration pneumonia. Regular diet, regular texture, thin liquids. R2's Minimum Data Set, (MDS), dated [DATE], documents, that R2 is cognitively intact and requires limited assist of 1-person physical assist with dining. R2's Significant Change MDS, dated [DATE], documents that R2 is mildly cognitively impaired. R2's current Care Plan documents, I (R2) am at risk for an ADL, (Activity of Daily Living), Self-Care Performance Deficit r/t, (related to), Activity Intolerance, Confusion, Fatigue, Impaired balance Date Initiated: 07/20/2023. Intervention: EATING: I require SUPERVISION/SETUP assistance of one staff participation to eat. Date Initiated: 07/20/2023 Revision on: 07/20/2023. 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: 146139 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 146139 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regency Care 2120 West Washington Springfield, IL 62702 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)