Autumn Meadows Of Cahokia

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

along the previous closure site and the entire below-knee flap was taken down. There was evidence of some nonviable (incapable of life or living) muscle and traumatized muscle from the fall as well as a hematoma (localized collection of blood that pools outside of blood vessels) which was evacuated (removed). There was a large amount of fibrous tissue in the posterior flap. An excisional debridement was preformed of these fibrous tissues. A portion of the tibial bone was exposed in the wound. Proximally a cm of tibial bone was then excised using a power saw. All the posterior flap was viable with no evidence of necrosis or ischemia. The wound was irrigated with an antibiotic solution, the posterior flap was brought anteriorly, and the previous skin incision was reapproximated using interrupted vertical sutures. The leg was dressed with Adaptic gaze, fluff gauze, kerlix wraps and an ace wrap. Resident R2's Progress Notes, dated 08/22/2025 at 4:00 PM, documented Resident R2 returned to the facility at this time. On 09/17/25 at 11:45 AM, V19, Medical Director said he would deem Resident R2 a fall risk and there should be a fall plan of care in place for him.

V19 stated the fall Resident R2 had has the potential to cause harm and he is sorry it happened. V19 said he thinks

the facility failed in preventing Resident R2's fall. He said no one was answering his call light, and his bed was broke that's a lot. He said yes, this incident has the potential for the resident to experience harm or death. He said it's unacceptable and he absolutely agrees the facility failed. The facility's Care Planning policy, effective date of 05/02/07, documented Comprehensive Care Plans The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS/RAI).

Each care plan will be dated indicating the date in which it was implemented. Each resident's comprehensive care plan should be designed to: o Incorporate identified problem areas; o Incorporate risk factors associated with identified problems; o Reflect goals and objectives in measurable outcomes; o Identify the professional services that are responsible for each element of care; o Aid in preventing or reducing declines in the resident's functional status and/or functional levels;o Enhance the optimal functioning of the resident and;o Build upon the strengths of the resident. The facility's Fall Prevention Protocol, reviewed dated of 03/2025, documented Standard: This facility is committed to establishing guidelines and procedures to minimize falls and their effects so as to maximize every resident's well-being.

It is established that it is impossible to prevent all falls due to their multi factorial nature, however this standard dictates a mode of action that attempt to identify, assess and implement interventions for each resident at risk and the facilitates an environment that is as safe as possible. It further documents Policy: I.

Fall Prevention/Risk Assessment A comprehensive fall risk assessment will be completed for every resident within 48-72 hours of admission/readmission and in conjunction with each required MDS assessment period and/or whenever the resident has a fall that is not consistent with previously identified risk factors.

This assessment shall include a review of the resident's physical status, cognitive function, functional status, environment and device use. Residents identified through the fall risk assessment as being at risk for falls shall have in place an interdisciplinary care plan that will address their risk by directing interventions towards the identified, modifiable etiologies or risk factors. Care plans will be revised and/or updated in conjunction with scheduled MDS assessments and repeat fall risk assessments.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Meadows of Cahokia

2 Annable Court Cahokia, IL 62206

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

FORM CMS-2567 (02/99) Previous Versions Obsolete

came and got him in his wheelchair and took him to the nurse's station for the nurse to assess. Resident R2 said he was bleeding all over the place. There was a trail of blood from the bed to the hallway. He said there was so much blood they had to take towels and put on it to stop it from bleeding. Resident R2 said it hurt bad, on a scale of 0-10 with 10 being the worst he said it was an 11. On 09/17/25 at 3:07 PM, V14, Maintenance Director stated he believes he found out Resident R2's bed was broken from a work order then he stated, no he made a note

in the meeting about the bed. He said they have a meeting every morning with the department directors, and he made a note about the bed. He said he would have to look for the notes from that day because he wasn't sure what day it was on. V14 said they had to replace Resident R2's bed because the locking mechanism did not work correctly, and the bed wouldn't lock, and was still able to move. On 09/18/25 at 10:40 AM, V1, Administrator stated she can't put a date on it when she was made aware of Resident R2's bed not working properly.

She said Resident R2 came in and then he had the fall, and it was sometime during that time frame that she was made aware. V1 was questioned if was before or after the fall and she said she was unable to remember and that is why she can't put a date on it. V1 said she would expect staff to fix it themselves if it was something they were able to fix if not she would expect them to put in a work order or report it to one of the nurse managers, and between maintenance and nursing they would get it fixed. On 09/17/25 at 11:45 AM, V19, Medical Director said he would deem Resident R2 a fall risk and there should be a fall plan of care in place for him. V19 stated the fall Resident R2 had has the potential to cause harm and he is sorry it happened. V19 said he thinks the facility failed in preventing Resident R2's fall. He said no one was answering his call light, and his bed was broke that's a lot. He said yes, this incident has the potential for the resident to experience harm or death.

He said it's unacceptable and he absolutely agrees the facility failed. The facility's Fall Prevention Protocol, reviewed dated of 03/2025, documented Standard: This facility is committed to establishing guidelines and procedures to minimize falls and their effects so as to maximize every resident's well being. It is established that it is impossible to prevent all falls due to their multi factorial nature, however this standard dictates a mode of action that attempt to identify, assess and implement interventions for each resident at risk and the facilitates an environment that is as safe as possible. It further documents Policy: I. Fall Prevention/Risk Assessment A comprehensive fall risk assessment will be completed for every resident within 48-72 hours of admission/readmission and in conjunction with each required MDS assessment period and/or whenever

the resident has a fall that is not consistent with previously identified risk factors. This assessment shall include a review of the resident's physical status, cognitive function, functional status, environment and device use. Residents identified through the fall risk assessment as being at risk for falls shall have in place

an interdisciplinary care plan that will address their risk by directing interventions towards the identified, modifiable etiologies or risk factors. Care plans will be revised and/or updated in conjunction with scheduled MDS assessments and repeat fall risk assessments.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Meadows of Cahokia

2 Annable Court Cahokia, IL 62206

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 0908 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

to the hallway. He said there was so much blood they had to take towels and put on it to stop it from bleeding. Resident R2 said it hurt bad, on a scale of 0-10 with 10 being the worst he said it was an 11. On 09/17/25 at 3:07 PM, V14, Maintenance Director stated he believes he found out Resident R2's bed was broken from a work order then he stated no he made a note in the meeting about the bed. He said they have a meeting every morning with the department directors, and he made a note about the bed. He said he would have to look for the notes from that day because he wasn't sure what day it was on. V14 said they had to replace Resident R2's bed because the locking mechanism did not work correctly, and the bed wouldn't lock, and was still able to move. On 09/18/25 at 10:40 AM, V1, Administrator stated she can't put a date on it when she was made aware of Resident R2's bed not working properly. She said Resident R2 came in and then he had the fall, and it was sometime

during that time frame that she was made aware. V1 was questioned if was before or after the fall and she said she was unable to remember and that is why she can't put a date on it. V1 said she would expect staff to fix it themselves if it was something they were able to fix if not she would expect them to put in a work order or report it to one of the nurse managers, and between maintenance and nursing they would get it fixed.V25, Regional Director stated the facility doesn't have an updated policy for maintenance as they are transitioning to a new system.

Event ID:

Facility ID:

If continuation sheet