Health inspection·December 17, 2023

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 record review and interview, the facility failed to prevent a safe and secure transfer for one of three (R1) residents reviewed for safe transfers in a sample of three. This failure resulted in R1 falling on 11/15/2023 and receiving a Displaced oblique distal diaphyseal fracture of the left femur. Findings Include: R1's V7/ Physician Assistant History and Physical, dated 11/15/2023, documents the following,(R1's) left leg shortened and internally rotated. Motor limited due to pain. R1's Trauma Level 2 History and Physical, dated 11/15/2023, from V8/ Orthopedic Surgeon documents, [AGE] year-old female Caucasian patient who was brought into the trauma bay, who fell from her wheelchair while being transferred in vehicle. (R1) was found to have a distal left femur fracture. Patient presents with left leg internally rotated, very tender. R1's X-Ray of the left femur, dated 11/15/2023, documents, Displaced oblique distal diaphyseal fracture of the left femur. The fracture is probably acute. Distal fracture fragment is displaced anteriorly and medially. The State Agency Notification report, dated 11/20/2023, documents,(R1) was being transferred to the facility from an appointment. Because of another driver, the facility driver was forced to stop the vehicle quickly. (R1) slipped to the floor of the van. The facility van driver called 911 immediately. (R1) was sent to the emergency room. (R1) sustained a closed fracture of the left femur. On 12/16/2023 at 1PM, R1 was laying in the bed resting, eyes appear to be closed. Resident did not respond when she was spoken to. On 12/16/2023 at 12:27PM ,V6/Transportation Aide, stated, I was taking (R1) to the hospital for a blood transfusion. On the way back to the facility, I went around a curb and there was a mail track stopped in the middle of the road. I was driving about 45 miles an hour and I had to suddenly stop very fast. (R1) had slid out of her wheelchair and onto the floor. (R1) was positioned between her wheelchair and the front console. I called 911 and then released the seat belt to give the paramedics room to take care of (R1). On 12/17/2023 at 1:35PM V1/Administrator stated, I was told by (V6/Transportation Aide) Page 1 of 2 145044 145044 12/17/2023 Allure of Peru 1301 21st Street Peru, IL 61354

F 0689 Level of Harm - Actual harm Residents Affected - Few that (R1) had slid out of her wheelchair, coming back from a blood transfusion. (V6) had to unexpectedly put the brakes on because there was a mail truck in front of her, so she had to stop suddenly or hit it. (R1) had a sling under [NAME] her, a personal chair alarm, and was very wet. (V6) said she had to release the seat belts and remove the wheelchair for the paramedics. (R1) was admitted to the local hospital with a fracture of the left femur. On 12/16/2023 at 11:45AM, V2/DON (Director of Nurses), stated,(V6/Transportation Aide) was taking (R1) for a blood transfusion. They were coming back and (V6) had to stop suddenly because a mail truck was parked in the way and (V6) was afraid she was going to hit the truck. (R1) slid out of her wheelchair landing on the foot pedals and must have hit the console. (R1) broke her left leg. R1's Nurses Notes, dated 11/15/2023, documents, Received a call from (V6/CNA/Transportation Aide) van driver stating that (R1) had been strapped in her wheelchair returning to the facility when the driver was forced to stop quickly. (R1) had slipped out of her chair, onto the floor. (V6) van driver states that (R1) was complaining of pain and 911 was called. (R1) was taken to a local hospital. (R1's) son was notified. The facility policy, Van Usage and Policy and Procedure, with no date, documents, When employees operate a facility van, they have inherent responsibilities to care for the vehicle and the residents, obey all state and local traffic laws and abide by drivers operating procedures. Procedure: 3.B.Wear seat belts anytime the vehicle is in motion and require all passengers to wear seatbelts. 3.C.Ensure all residents and wheelchairs are safely secured. 145044 Page 2 of 2