Inspection·December 6, 2024

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 and record review, the facility failed to provide an appropriate number of staff to assist in a transfer in 1 of 5 residents (R2), reviewed for falls in the sample of 7. Findings include: R2's Face Sheet, undated, documents R2 has the following diagnoses: Fracture of the Thoracic Vertebra, Pulmonary Embolism (PE), Fusion of Spine, Post Laminectomy Syndrome and Spinal Stenosis. R2's Minimum Data Set, dated [DATE], documents R2 has a Brief Interview for Mental Status Score of 13, indicating R2 is cognitively intact, requires partial/moderate assist with transfers and has a history of falls with fractures. R2's Care Plan, dated 8/30/24, documents R2 is at risk for falls with interventions dated 9/23/24 to have therapy evaluate R2's transfer status and educate staff on R2's transfer status. R2's care plan goes on to document that R2 has an activities of daily living deficit with and requires an assistance of two with transfers. R2's Progress Note, dated 9/22/24 at 9:45 AM, documents the following: Summoned to guest's room per CNA (Certified Nursing Assistant). Guest sitting on floor in bathroom facing the wall next to the toilet. Guest states she was assisted to bathroom with CNA using wheelchair. Upon attempting to stand from wheelchair with assist, guest states her knees gave out and she sat down on the floor. She denies any pain, just weak. Guest requesting not to go to hospital, states she would like to get back in the bed. Guest assisted back to wheelchair and then to bed with assist of 2 using gait belt. R2's Physician notified with NNO (no new orders). Guest's son also notified of incident. Continuing to monitor closely. R2's Fall Event Investigation, dated 9/22/24, documents R2 fell while transferring off of the toilet with assist, knees gave out and R2 was assisted to the floor. The interventions are as follows: therapy to evaluate transfer status, staff educated on transfers, R2 to use a full mechanical lift until therapy evaluates R2. R2's Mobility [NAME], completed by the therapy department, dated 9/23/24, documents R2 requires an assist of 2 staff with a transfer belt for transfers to the wheelchair/bed and toilet. R2's Progress Note by V11, Licensed Practical Nurse (LPN), dated 9/30/24 at 4:16 PM, documents the following: CNA approached writer around 3:40 PM and stated resident had fallen when getting up from (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: 146160 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 146160 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springfield Suites Rehab and Nursing 3089 Old Jacksonville Road Springfield, IL 62704 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)