Health inspection·December 13, 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 observation, interview and record review, the facility failed to utilize a gait belt while transferring a resident and failed to ensure that fall interventions were put into place for 2 of 15 residents (R116 and R21) reviewed for falls in the sample of 41. Findings include: 1. On 12/07/23 12:15 PM R116 was sitting in her wheelchair (w/c) in her bathroom after being assisted with toileting by V5 (Certified Nursing Assistant/CNA). V5 then pushed R116 in her w/c to her bedside and assisted her to stand and pivot and lay down in bed. V5 did not put a gait belt around R116 to transfer her. R116 stated she had two falls before coming to the facility and broke her back. She stated she hit her head both times. R116 stated they have told her not to transfer by herself without assist. R116's Resident Care Summary dated 12/1/23 documents R116 requires assist of 1-2 for toileting, assist of 1-2 for positioning, assist of 1-2 for transferring and assist of 1-2 for mobility with wheelchair assisted. It documents R116 is receiving Physical Therapy and Occupational Therapy. On 12/08/23 at 3:14 PM V2 (Director of Nursing/DON) stated if staff must lay hands on a resident to assist them to transfer from the toilet to the w/c or w/c to bed, they should use a gait belt during the transfer for resident safety. On 12/12/23 at 10:45 AM V5 (CNA) stated she should have used a gait belt when she transferred R116 from the toilet to her w/c and from her w/c to her bed because R116 can do really good when transferring on some days but can be weaker and more unsteady on other days. V5 stated that was a crazy day when she was observed not using the gait belt when she transferred R116 from the toilet to her w/c and then from the wheelchair to her bed, but she should have still used the gait belt during the transfer. 2. R21's Physician Order Sheet (POS) dated December 2023 documents a diagnosis of Neurocognitive disorder with Lewy bodies, Dementia in other disease classified elsewhere, anxiety, unspecific severity with psych disturbances, GERD (Gastroesophageal Reflux Disease) , paroxysmal A-fib (Atrial Fibrillation), spinal stenosis collapsed vertebra, hypothyroidism, overactive bladder, vitamin D deficiency, major depression disorder, hypertension, personal history of COVID, hypothyroidism, low back pain, and solitary pulmonary nodule. R21's Minimum Data Set (MDS) dated [DATE] document R21 was severely impaired for decision making of (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: 146142 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 146142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meridian Village Care Center 27 Auerbach Place Glen Carbon, IL 62034 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)