Health inspection·April 14, 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 interview and record review, the facility failed to provide a resident with adequate staff supervision during a shower for a resident who requires substantial maximal assistance with bathing/showering. This failure applies to one of three residents (R2) reviewed for accidents/supervision and resulted in R1 sustaining a femur fracture. Findings include: R2 has a diagnoses history of Paraplegia, Multiple Sclerosis, Morbid Obesity, and Cognitive Communication Deficit who was admitted to the facility 04/06/2024. The facility's Incident Investigation Report dated 04/09/2025 documents on 04/01/2025 R2 was taken for her regularly scheduled shower, she was set up with her items per usual with the shower chair locked, she reported she dropped the towel and when she reached down to grab the towel, she slid from the shower chair; Upon interview with the CNA (Certified Nursing Assistant) stated she set the resident up per her request, lathered the soap and towel and allowed her privacy per the resident's request; R2 was admitted to the hospital for closed fracture of the distal left femur; R2 is at high risk for falls due to weakness and impaired mobility, she is paraplegic, has limited range of motion to her left upper and lower extremities to where she will require staff assistance; based on staff interviews, R2 clearly prefers and or requests privacy during showers so staff should always respect that preference by allowing sufficient space and avoiding unnecessary exposure; This includes maintaining a respectful distance while offering assistance that maintains that privacy; Plan of care in place and updated. Witness statement from R2 dated 04/03/2025 documents the Director of Nursing called R2 on the phone to interview her regarding her fall in the shower room and R2 reported on 04/01/2025 her CNA (Certified Nursing Assistant) V4 set her up in the shower, when she reached for a towel that fell, she slid from the shower chair. Undated Witness statement from V4 (CNA) documents she placed R2 in the chair and transported her to the shower room and R2 informed her that she would use the call light when she was ready to come out so she will set everything up for her, R2 requested her privacy and she is alert and oriented to person, place, time, and situation; the chair was locked to secure her, R2 informed her she tried to reach and grab her towel and fell over in the chair. Undated Witness statements from V8 (Registered Nurse) and V9 (Licensed Practical Nurse) stated they heard R2 yelling for help in the shower room and responded to assist, and she reported she dropped Page 1 of 4 145208 145208 04/14/2025 Pavilion of Bridgeview, The 8100 South Harlem Avenue Bridgeview, IL 60455

F 0689 her towel and fell from the chair. Level of Harm - Actual harm R2's Fall Risk Evaluation dated 04/06/2024 documents she had 1-2 falls in the past three months, and had predisposing risk factors including 1-2 predisposing diseases present, balance problem while standing, requires use of assistive devices, and takes 1-2 high risk medications. Residents Affected - Few R2's Quarterly Minimum Data Set assessment dated [DATE] documents she requires substantial maximal assistance with most activities of daily living including bathing/showering self, and tub/shower and toilet transfers. R2's Current Care Plan initiated 04/08/2024 documents she has an ADL (Activity of Daily Living) self-care performance deficit related to Hemiplegia, Impaired balance, Limited Mobility, and Limited ROM. R2 has weakness and impaired mobility she has a diagnosis of Multiple Sclerosis. R2 is a paraplegic and has limited range of motion to her Left upper and Lower extremities. She requires staff assist. She has spasticity and rigidness to extremities that inhibit movement; she is non ambulatory and transfers via sit to stand with assist with interventions including: she requires extensive assist of (1-2) staff to provide bath/shower twice a week and as necessary; and R2 requires Mechanical Lift (sit to stand) with (2) staff assistance for transfers. R2's Current Care Plan initiated 04/08/2024 documents she is at risk for incontinence related to Impaired Mobility, Physical limitations due to weakness and impaired mobility, having diagnoses of Multiple Sclerosis, Paraplegia and requires staff assist; she is non ambulatory and transfers via sit to stand with assist with interventions including check every two hours, upon request, and as needed for incontinence. R2's Current Care Plan initiated 04/06/2024 documents she is at risk for falls due to weakness and impaired mobility, and diagnoses of Multiple Sclerosis and Paraplegia and has limited range of motion to her left upper and lower extremities, and requires staff assist; R2's Current Shower/Bathing Care Plan initiated 11/06/2024 documents she enjoys her shower on scheduled days and would prefer privacy at times. R2's Incident progress note dated 4/1/2025 at 5:00 PM documents she was heard screaming for help in the shower room. Staff observed she was on her knees, leaning forward with left shoulder against the wall then sat back placing her buttocks on the floor and legs bent backwards on each side. Shower room call light is not on. R2 verbalized that she is taking her shower and was trying to get a towel, but the chair flipped over, and she ended on the floor. Her left leg is in severe pain, and she complained of severe pain on left leg. Physician notified and ordered to call 911 due to possible fracture or dislocation; at 11:21 PM Post Fall Evaluation documents the fall was not witnessed. Fall occurred in the bathroom. Resident was reaching for item(s) at time of the fall; Fall resulted in an emergency room visit/hospitalization and R2 was admitted due to a closed fracture of left femur. R2's progress note dated 4/2/2025 at 03:03 AM documents she was admitted to Christ Hospital with an admitting diagnosis of a closed fracture to left femur. R2's Fall Risk assessment dated [DATE] documents she was heard screaming for help from the shower room, staff observed her on her knees with the shower room call light not on, she reported she was taking her shower and was attempting to get a towel, her chair flipped over and she ended up on the floor and her left leg is in severe pain with predisposing situational risk factors included requesting privacy during her shower. R2's Hospital Report dated 04/01/2025 documents she received an Orthopedic Surgery Consult due to left femur fracture, she presented with left knee pain after a fall in the shower, her Multiple Sclerosis limits her ability to ambulate, emergency department x-rays revealed a distal femur fracture. 145208 Page 2 of 4 145208 04/14/2025 Pavilion of Bridgeview, The 8100 South Harlem Avenue Bridgeview, IL 60455

F 0689 Level of Harm - Actual harm Residents Affected - Few On 04/14/2025 at 10:19 AM V6 (Restorative Aide) stated she's worked in the facility for nearly five years. V6 stated she is familiar with R2 and she had been in the facility nearly a year. V6 stated R2 was very alert. V6 stated R2 did not have a history of refusing care. V6 stated R2 requires sit to stand assistance with a mechanical lift for transfers with two person assistance. V6 stated R2 was able to reposition her legs in the sit to stand equipment, could hold on to the bars on the mechanical lift however her hands were shaky. V6 stated R2 could sometimes unhook herself from the sling. V6 stated R2 needed staff to provide her with incontinence care and could not clean herself after an incontinent episode. V6 stated she has had experience showering R2 and R2 would allow her to be present while she was in the shower. V6 stated there is typically one person in the shower with R2. V6 stated R2 needed assistance with showering. V6 stated she would let R2 clean her face, neck and upper body and she would try to clean her bottom however because of the shakiness of R2's hands she would assist her with cleaning her lower body. V6 stated R2 has never asked her to be left unattended while in the shower. V6 stated if R2 did ask for privacy during a shower, she wouldn't be able to leave her unattended however she could have possibly turned her back or pulled the curtain closed. V6 stated however, she would not have been able to leave R2 unattended. V6 stated she cannot leave a resident unattended in the shower that is not independent. V6 stated she could notify the nurse that R2 requested privacy during a shower, but couldn't leave her unattended. On 04/14/2025 at 10:42 AM V7 (Certified Nursing Assistant) stated she has worked at the facility for four months and has worked with R2 only a few times. V7 stated R2 would ask for privacy while having a bowel movement and we would usually just step outside the door but never too far away. V7 stated R2 required sit to stand assistance with a mechanical lift for transfers with two-person assistance. V7 stated R2 is relatively independent and likes to do things on her own but during showers a staff would always be with her. V7 stated she has never provided a shower to R2 however if R2 requested privacy during a shower she would have closed the curtain and stayed inside the shower. V7 stated the shower is relatively big and she could stand on the opposite side with the curtain closed. V7 stated there is no situation she could think of where she would leave R2 alone in the shower. V7 stated she wouldn't leave R2 alone in the shower because of her fall risk and in case she needed help with something. On 04/14/2025 at 11:00 AM V4 (Certified Nursing Assistant) stated she did not work with R2 often. V4 stated R2 was alert and oriented times four. V4 stated 04/01/2025 may have been her first time working with R2. V4 stated she assisted R2 to the shower on 04/01/2025 sometime after 3PM during the second shift. V4 stated when she and R2 arrived to the shower, she set R2 up, handed her all her personal items, put on her shower cap and shoes, locked her chair, and handed her the call light because R2 requested for her to step out and give her privacy. V4 stated she insisted on staying in the shower to help R2, however R2 was adamant about her stepping out and giving her privacy to shower herself. V4 stated she stepped out of the shower within arm's reach and then afterward heard R2 fall in the shower. V4 stated R2 reported to her verbatim that she dropped her towel, tried to reach over and pick it up and ended up slipping out of the chair. V4 stated she was not inside the shower room when this incident took place but was within arm's reach outside the shower room door. V4 stated R2 required moderate assistance and sometimes supervision for the majority of daily tasks. V4 stated R2 requires a sit to stand for transfers which is provided by the aide but other than that can do things for herself. V4 stated R2 has physical limitations from the legs down but is able to perform other hygiene tasks on her own. V4 stated if residents that need assistance for transfers and hygiene tasks ask for privacy while showering, she has to respect that, and was always told they have the right to have privacy if they are alert and oriented. On 04/14/2025 at 12:11 PM V3 (Director of Nursing/Registered 145208 Page 3 of 4 145208 04/14/2025 Pavilion of Bridgeview, The 8100 South Harlem Avenue Bridgeview, IL 60455

F 0689 Level of Harm - Actual harm Residents Affected - Few Nurse) stated she spoke to R2 on 04/03/2025 as part of the investigation into her fall incident on 04/01/2025. V3 stated R2 told her on 04/01/2025 she was in the shower washing her upper body, the towel dropped to the floor and she went down to grab the towel and she flipped over. V3 stated she asked R2 did she ask for assistance during this incident and asked her why didn't she pull the call light and R2 replied she had the call light and thought she could reach the towel herself and when she bent down the call light was no longer in reach. V3 stated when she interviewed V4 (Certified Nursing Assistant) she said she had literally just stepped outside the door because R2 insisted she wanted her privacy during her shower. V3 stated that V4 informed she set R2 up in the shower room, asked her if she wanted her to stay, R2 replied no she wanted her privacy, and V4 honored her request. V3 stated V4 reported her cart was across on the other side of the wall and she went to grab something off of the cart and R2 was heard yelling for help. V3 stated R2 requires sit to stand with transfers and as far as bathing she knows she requires the extensive assistance of one staff member but is care planned for two if she needs extra assistance because she has Multiple Sclerosis. V3 stated as far as she knows there is usually one staff assisting R2 with showers and they promote R2's independence with cleaning areas that she can reach and clean herself such as her upper body. V3 stated R2 can't reach her back or peri area. V3 stated based on the level of assistance R2 needs there should be a staff present as much as needed for her safety. V3 stated with R2 being a relatively younger lady we should provide a level of independence as well as keeping her safe so there's always a fine line and we have to keep them safe and promote their autonomy. V3 stated ways to promote privacy for R2 is having staff at arm's reach, if there's a shower curtain pull the curtain back, step off to the side, or be in a position to be able to reach her if she needs assistance such as if she drops a towel or if she's ready for them to wash her back or needs an extra item. V3 stated yes staff should educate R2 on her safety needs if she requests them to leave the shower room and provide her with privacy. V3 stated the shower bath policy states we should never leave the resident unattended and the fall management policy does state that the facility has to honor their preferences while keeping them safe and therefore V4 should have been with R2 but felt she was honoring her request for privacy as well. V3 stated, do we leave residents unattended?; no. V3 stated in this instance although R2 was asking for privacy and it was her choice, she cannot refute the policy. V3 stated if R2 still insists on privacy during showers the staff can ask the nurse for assistance as well. The facility's Shower/Tub Bath Policy received 04/10/2025 states: Stay with the resident throughout the bath. Never leave the resident unattended in the tub or shower. The facility's Fall Management Policy received 04/10/2025 states: The facility's challenge is to balance protecting the resident's right to make choices and the facility's responsibility to comply with regulations. The responsibility to respect a resident's choices is balanced by considering the potential impact of these choices on other residents and the facility's obligation to protect the residents from harm. The facility will educate the resident regarding significant risks relate to a residents choice. 145208 Page 4 of 4