Health inspection·June 2, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure wheelchair pedals were in place prior to propelling a resident in a wheelchair for one of three residents (R1) reviewed for falls on the sample list of three. This failure resulted in R1 falling from the wheelchair onto the tile floor and suffering a subarachnoid hemorrhage that required an overnight hospital stay. Findings Include: R1's Care Plan dated 05/09/2025 documents R1 is diagnosed with Dysphagia, Unspecified Psychosis, Dysarthria following Cerebral infarction, Hemiplegia, Muscle Weakness, Seizures, Major Depressive disorder, Unsteadiness on Feet, Other abnormalities of gait and mobility, lack of coordination, History of Falling, unspecified Dementia, and Diabetes. R1's Care Plan dated 05/09/2025 documents R1 is at risk for falling related to weakness. R1's care plan does not document R1 as dependent for wheelchair mobility or interventions for R1 for refusing to use foot pedals during transfers/propelling by staff. R1's Physician Order Sheet dated June 2025 documents R1 was prescribed an anti-platelet medication in of February 2025. R1's Minimum Data Set documented as completed on May 8, 2025, documents under section C completed on April 30, 2025, that R1 is cognitively intact. Section GG completed on May 8, 2025, documents that R1 uses a wheelchair and requires substantial/maximal assistance for transfers, bed mobility, and activities of daily living. V2's, (Director of Nursing (DON)), Progress Note dated 5/8/2025 at 10:37 AM documents on 5/7/25 at 4:31 PM R1 was in the dining room on the floor on R1's left side. The same note further documents R1 was in her wheelchair, being transported by an activity aide (V7) to her room to be changed prior to the fall. V10's (Registered Nurse) Progress Note dated 5/8/2025 at 05:39 AM documents R1 was admitted to the intensive care unit for subarachnoid hemorrhage. R1's After Visit Summary dated 5/8/25 at 1:55 PM from the local hospital documents R1 was admitted to the hospital on [DATE] after a ground level fall and that a Computed Tomography scan of R1's brain documented a small acute subarachnoid hemorrhage over the right frontal lobe anteriorly and a large left frontal subcutaneous hematoma. Page 1 of 2 145031 145031 06/02/2025 Loft Rehab & Nursing of Normal 510 Broadway Normal, IL 61761

F 0689 Level of Harm - Actual harm Residents Affected - Few On 5/28/25 at 09:45 AM R1 was sitting in the common area in her wheelchair with foot pedals attached to the wheelchair. R1 had a half dollar sized raised hematoma on the left side of her forehead. R1 was only alert to person and place. On 5/28/25 at 11:45 AM V7, Activity Assistant, stated V7 was propelling R1 in the wheelchair from the table in the dining room to take R1 to her room to be changed due to being incontinent of urine and R1 put her feet on the floor while R7 was propelling the wheelchair and R1 fell forward from the wheelchair and hit her head on the floor. V7 stated R1 did not have foot pedals on the wheelchair and is dependent on staff to propel R1 around the facility. On 5/28/25 at 10:34 AM V3 Occupational Therapy, stated every wheelchair issued has foot pedals. V3 stated R1 has had foot pedals for the wheelchair for a long time but that they are not often used. V3 stated R1 has been known to refuse foot pedals on occasion. On 5/28/25 at 11:38 AM V8, Certified Nursing Assistant, stated R1 does not self-propel the wheelchair. V8 stated V8 does not recall R1 having foot pedals prior to the fall of 5/7/25. V8 stated R1 now has foot pedals attached to the wheelchair. On 5/28/25 at 11:40 AM V9 Certified Nursing Assistant, Stated R1 did not have foot pedals prior to the documented fall of 5/7/25 and did not self-propel wheelchair. V9 stated staff propelled R1 around the facility. V9 confirmed it was possible for R1 to have fallen and hit her head at any time due to the non-use of foot pedals. On 5/28/25 at 1:30 PM V2 Director of Nurses (DON) confirmed V7 was propelling the wheelchair when R1 fell and the wheelchair R1 was using did not have foot pedals on at the time of the fall. On 06/02/2025 at 11:45 AM V11, Certified Nurse Assistant, stated R1 has not propelled herself in a very long time and is dependent on staff for mobility in the wheelchair. The facility's Fall Prevention Program dated 02/12/2025 documents the program's purpose is to assure the safety of all residents in the facility and is to include measures which determine the individual needs of each resident by assessing the risk of falls, implementing appropriate interventions to provide necessary supervision, and using assistive devices as necessary. A Fall Risk Assessment should be performed at least quarterly and with each significant change in mental or functional condition and after any fall incident. Safety interventions should be implemented for each resident identified at risk. Section J. documents to Provide additional interventions as directed by the resident's assessment, including but not limited to: 1. Assistive devices. 145031 Page 2 of 2