Health inspection·March 21, 2025

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 ensure resident safety by failing to have two staff members present when providing a mechanical lift transfer. This failure affects one (R4) of three residents reviewed for fall prevention program. Findings include: On 3/18/25 at 12:20PM, V2 (Director of Nursing) said that when alleged incident with R4 occurred V6 (Certified Nursing Assistant/CNA) had placed the Mechanical lift sling on backwards and R4 slid out onto the floor. V6 was doing a mechanical lift transfer for R4 by herself. On 3/18/25, at 12:27pm, V4 (Licensed Practical Nurse/LPN) said that he was called to the room by other staff members V5 (LPN) and V6 (CNA) and when he entered the room observed R4 on floor next to Mechanical lift machine. V4 said that Mechanical lift transfers are supposed to be a two person transfer assist. On 3/18/25 at 1:12PM, V5 (LPN) said that she was the nurse on duty for the alleged incident with R4. She heard a scream coming from R4's room and when she entered the room V5 observed R4 on the floor. R4 was with V6 (CNA) in room. V5 said the mechanical lift sling was not ripped or torn. V5 said that V6 did not ask for assistance with transfer, it was only her in the room. V5 said that when a mechanical transfer is to be done there should always be a two person assist for transfer. On 3/18/25 at 1:22PM, V6 (CNA) said that she was taking care of R4 on the day of the incident. V6 said that there was no Mechanical sling in her room not aware of what happened to her sling and used a different sling from the basement, the sling was not torn or ripped. V6 said that R4 is a two person assist for transfers and V6 did not ask for assistance when using the Mechanical lift. V6 said she works night shift and sometimes there is not enough staff to have a two-person transfer. On 3/19/25 at 10:29AM, R4 said that on alleged date of incident that V6 (CNA) put the Mechanical lift sling on backwards, when V6 lifted her up she came down, sliding off the sling onto the floor. R4 said that the lift sling was not ripped or torn, that the sling was put on backwards, said that V6 was the only one in the room doing the transfer. R4 said that there is always no help at night for transfers. R4's admission date on 5/25/24 with diagnosis listed in part but not limited to other low back pain, chronic obstructive pulmonary disease, morbid obesity, cerebral palsy, other seizures, unspecified diastolic heart failure, paraplegia, unspecified, hyperlipidemia, GERD, osteoarthritis of knee, Page 1 of 2 145197 145197 03/21/2025 Aperion Care Oak Lawn 9401 South Ridgeland Avenue Oak Lawn, IL 60453

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few major depressive disorder. Most recent fall assessment dated [DATE] indicated that she is at high risk for fall. MDS section C-Cognitive Patterns indicate a BIMS score of 15. MDS section GG Functional abilities and goals: GG0130 Self-Care indicated Toileting hygiene, Shower/bathe, Lower body dressing and putting on/taking off footwear were coded 01- Dependent, Helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity. MDS section GG Functional abilities and goals: GG0170 Mobility indicated sit to lying, lying to sitting, lying to sitting on side of bed and Chair/bed-to-chair transfer were coded 01-Dependent, Helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity. Comprehensive care plan indicates: I have an ADL self-care/mobility performance (functional abilities) deficit with Intervention: use a mechanical lift for transfer assist Mechanical lift with 2 staff. R4's fall incident report dated 03/06/2025 at 07:14AM completed by V5 (Licensed Practical Nurse) indicated: Resident stated while CNA was attempting to transfer from bed to wheelchair she slid out of Mechanical lift. Facility's policy on Transfers-Manual Gait Belt and Mechanical lifts Revised 1-19-18 Purpose: In order to protect the safety and well-being of the Staff and Residents, and to promote quality care, this facility will use Mechanical lifting devices for the lifting and movement of Residents. Guidelines: 5. The transferring needs of residents will be assessed on an ongoing basis and designated into one of the following categories: 0 =independent 1=1 person transfer (25% or less assistance from caregiver) with gait belt. 2=2 person transfer with gait belt (ONLY when use of mechanical lift is not provided) SS= Sit to Stand Lift with 2 caregivers H= Mechanical Lift with 2 caregivers. Fall Prevention Program revised 11-21-17 Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Fall/Safety interventions may include but are not limited to: -Transfer conveyances shall be used to transfer residents in accordance with the plan of care. 145197 Page 2 of 2