Health inspection·January 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 ensure safe incontinence care for 1 of 3 residents (R1) reviewed for safety. This failure resulted in R1 rolling off the bed onto the floor and sustaining a cervical fracture, a left clavicle fracture, and laceration to her left eyebrow requiring 3 sutures. The findings include: R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include dysphagia, hyperlipidemia, Type 2 Diabetes, spondylosis without myelopathy, generalized anxiety, depression, and arthropathy. R1's facility assessment dated [DATE] showed she has severe cognitive impairment and requires substantial to maximum assist for bed mobility. R1's care plan initiated 6/5/23 showed, . Self care deficit, requires staff assist with ADLs (activities of daily living)related debility, weakness . Bed Mobility- extensive assist Toileting - extensive assist, incontinence care . On 1/2/25 at 11:00 AM, R1 was lying in her bed. R1 had a brace on her neck and a sling on her left arm. R1's acute care hospital documentation dated 12/29/24 showed, . Today's Visit . Reason for Visit: Fall . Diagnoses: Other closed nondisplaced fracture of first cervical vertebra, Closed nondisplaced fracture of acromial end of left clavicle, eye laceration Avulsion of skin of left forearm . R1's facility incident report dated 12/29/24 showed, 12/29/24, at approximately 1:18 AM the resident was reportedly receiving care when the resident rolled out of the bed and landed on her left side. The resident sustained a laceration to the left eyebrow and a skin tear to the left elbow. First aid was immediately rendered. the resident complained of left shoulder pain . The resident was transferred to the local ED (emergency department) via EMS (emergency medical services) where the laceration to the left eyebrow was repaired with three sutures. Additional imaging was performed which displayed new fracture of the C1 vertebrae and acute fracture of the distal clavicle . R1's 12/28/24 nursing note entered at 1:03 PM showed, Alert, pleasantly confused and able to make needs known. Compliant with medications, took crushed in applesauce without difficulty. Appetite adequate and ate both breakfast and lunch in the dining room. able to propel self short distances in wheelchair, without difficulty. Incontinent of bowel and bladder, peri care provided PRN (as needed). Resident up in wheelchair at this time near nurses station. No complaints of signs and symptoms of Page 1 of 3 145312 145312 01/02/2025 Symphony Northwoods 2250 Pearl Street Belvidere, IL 61008

F 0689 pain/discomfort verbalized or displayed . Level of Harm - Actual harm R1's 12/29/24 nursing note entered at 1:29 AM showed, Resident was being changed by CNA (Certified Nursing Assistant) at the time of fall. Resident rolled to her right side and she didn't stop rolling which resulted in fall to floor. Landed on her left side on floor. Received cut to left upper, outer eyebrow and a left elbow skin tear. Areas cleaned and dressing applied to left elbow. Pressure held to left eyebrow until bleeding stopped. Resident hoyer lifted back to bed. Complained of left shoulder pain. On call NP notified Resident taken by EMS (emergency medical services) to [acute care hospital] . Residents Affected - Few R1's 12/29/24 nursing note entered at 4:16 AM showed, MD (Medical Doctor) called . Resident being transferred to [a neighboring acute care hospital] for admission due to a C1 (cervical vertebrae) fracture . R1's 12/29/24 nursing note entered at 5:41 AM showed, . ER (Emergency Room) called facility and resident is to return to the facility. Need to make appointments with ortho and neurosurgery on Monday. PRN (as needed) Tramadol (pain medication) ordered . Resident came back by ambulance at this time. Aspen collar (neck stabilizer) on and sling to left arm due to collarbone fracture . R1's care plan initiated 4/6/23 showed, Potential for falls, Resident at risk for injury from falls . Interventions: (12/29/24) 2 staff assist resident with turning and repositioning in bed for cares . Aspen collar at all times, may release for skin checks and hygiene . Sling to LUE (left upper extremity) at all times, may remove for showers/skin checks . On 1/2/25 at 1:06 PM, V5 CNA (Certified Nursing Assistant) said she was changing R1 on 12/29/24 when she rolled out of bed and onto the floor. V5 said, I was on her left side and turned her onto her right side. When I turned her she continued to roll out of the bed. I am not sure what happened. I'm not sure if I rolled her too far . She was pretty much asleep when I was changing her After she fell she was saying 'ow ow, I'm in pain' . I had taken care of the her previous night too. She was a difficult turn. She is listed as a one assist but she doesn't help turn at all. On 1/2/25 at 1:13 PM, V3 RN (Registered Nurse) said, I didn't witness anything until after she was on the floor. I was told by the CNA that she was changing her and she rolled out of the bed. I got there and she was sitting on the floor on the left side and she was bleeding. I assessed her and they hoyered her back up into bed. Once I went in and reassessed her she was complaining of pain. I went and called 911 . I thought it was ridiculous . when you turn them you make sure they are stable before you take your hands off of them . On 1/2/25 at 3:05 PM, V6 RN (Registered Nurse) said R1 is an extensive assist of one and sometimes two assist depending on the day. V6 said R1 is definitely a difficult change (incontinence change) and it has been getting harder since she has been declining. V6 said they have usually been using two people but with agency staff she feels like they go and attempt care and don't get assistance until they realize how difficult the resident is. On 1/2/25 at 3:35 PM, V2 DON (Director of Nursing) said R1 was struggling with turning and rolling and being able to assist with that. V2 said after R1's fall, they changed her to a two assist with incontinence care and bed mobility. The facility's policy with revision date of 8/1/23 showed, Fall Prevention Guideline . General: It 145312 Page 2 of 3 145312 01/02/2025 Symphony Northwoods 2250 Pearl Street Belvidere, IL 61008

F 0689 is the intent of this facility to provide residents with assistance and supervision in an effort to minimize the risk of falls and fall related injuries . Level of Harm - Actual harm Residents Affected - Few The facility's policy with revision date of 3/2024 showed, Falls Management . General: This facility is committed to maximizing each resident's physical, mental and psychosocial wellbeing. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventative strategies, and facility as safe an environment as possible . 145312 Page 3 of 3