F0689

D

Failure to Maintain Safe Environment and Adequate Fall Prevention for Cognitively Impaired Residents

Mattoon, Illinois Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and fall interventions for cognitively impaired residents at risk for falls. The facility’s Skilled Fall Policy requires completion of an occurrence report after each fall to determine root cause and implement interventions. For one resident with severe cognitive impairment and a care plan identifying fall risk related to muscle weakness, dementia, impaired hearing and vision, impaired balance, and a history of falls, the care plan included interventions such as “call don’t fall” signage and nonskid grip strips in the bathroom, in front of the bathroom door, in front of the recliner, and on the bathroom floor. During a fall on 1/10/26, the resident was found on the floor in front of the toilet with pants down and incontinent of bowel movement after attempting to go to the bathroom, and the MDS Coordinator noted the grip strips in front of the toilet were worn down and replaced them. The fall investigation did not document when the resident was last toileted prior to the fall.

A subsequent fall for the same resident on 1/19/26 occurred after a room change. The resident, who normally used the call light, was described as more confused that night and attempted to get up unassisted from a recliner and fell in front of the bathroom. Staff interviews and interdisciplinary notes indicated that the resident was more confused due to the recent room change and attempted to self-transfer. There was no documentation that the new room had the previously care-planned “call don’t fall” signs and nonskid grip strips in place at the time of the fall. The DON confirmed that grip strips and “call don’t fall” signs were current interventions that should have been moved with the resident during the room change and that the fall investigation did not document whether these interventions were in place when the resident fell.

Another resident with severe cognitive impairment and requiring partial/moderate assistance for transfers experienced multiple falls where investigations lacked key information and environmental hazards were not fully addressed. A fall on 12/19/25 occurred when the resident was found sitting on the floor beside the bed, later documented as an attempted self-transfer from wheelchair to bed with incontinence at the time of the fall; the investigation did not identify the last time the resident was toileted, and a new intervention of nonskid grip strips next to the bed was added. A later fall on 2/3/26 involved the resident falling from a wheelchair in the hallway with the wheelchair tipped and a foot pedal under the resident; the investigation did not identify whether a nonskid mat was in the wheelchair, though the care plan was updated to replace the nonskid mat. Another incident on 2/19/26 occurred during a staff-assisted transfer when a CNA’s foot became caught on a floor mat, causing loss of balance and the resident being lowered to the floor, resulting in a skin tear; the DON later confirmed that the post-fall intervention was to pick up the floor mat when the resident was out of bed.