Health inspection·May 23, 2024

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 provide two person assistance during incontinence care and failed to implement a post fall intervention. This failure applies to 1 of 3 residents (R1) reviewed for falls in the sample of 3. This failure resulted in the resident falling off the bed and sustaining a left femur and a right shoulder fracture. The findings include: R1's EMR (electronic medical records) showed that R1 was sent to the ER (emergency room) on May 9, 2024 post fall and readmitted to the facility on [DATE] after hospital stay with diagnoses of unspecified fall, subsequent encounter, nondisplaced fracture of lateral condyle of right femur, subsequent encounter for closed fracture with routine healing, fracture of unspecified shoulder girdle, part unspecified, subsequent encounter for fracture with routine healing, unspecified injury of head, subsequent encounter. R1's diagnoses prior to discharge to the hospital included morbid (severe) obesity due to excess calories, other idiopathic peripheral autonomic neuropathy. Initial Consultation at ED (Emergency Department) on May 9, 2024 included the following information: R1 is a [AGE] year old female presented to ED for further evaluation after mechanical fall out of bed at the nursing home. R1 is on Xarelto (blood thinner) and primarily complained of headache where she hit her head, right shoulder pain and left knee and hip pain. ED evaluation with X-ray to shoulder shows comminuted displaced right neck humeral fracture primarily involving the humeral neck which is displaced up to 1.7 cm (centimeters) and also involves the humeral head cortex and tuberosities, soft tissue edema present. CT (Computed Tomography) of left knee shows fracture of both medial and lateral distal femur essentially nondisplaced extending into the tibiofemoral articular surface as well as patellofemoral articular surface. Orthopedic surgery was consulted for further management. R1's quarterly MDS (minimum data set) dated March 5, 2024 showed that R1 was moderately impaired in cognition. The same MDS showed that R1 was dependent on staff for toileting hygiene. The MDS assessment showed that the term dependent included that 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. R1's Fall Risk assessment dated [DATE] showed that R1 was at high risk for fall with a score of 16. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 145246 Printed: 05/15/2026 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 145246 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Hinsdale, The 600 West Ogden Avenue Hinsdale, IL 60521 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)