Health inspection·July 21, 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 put interventions in place after a resident fall to protect the resident from future falls. This failure resulted in R1 falling in his room and sustaining 4 fractured ribs on 5/27/25. This applies to 1 of 3 residents (R1) reviewed for fall interventions in the sample of 7. The findings include: R1's EMR (Electronic Medical Record) dated 5/21/25 states, Resident observed laying on the floor next to his bed on his right side. Resident tried to get self up from his bed and slid to the floor. No injuries noted, no pain or discomfort verbalized or demonstrated . Resident transferred back to bed .R1's Care Plan dated 12/17/24 states, Potential for falls, Resident at risk for injury from falls, history of falls. The intervention UA sent to rule out infection shows a date initiated as 5/23/2025. No other interventions were put in place to prevent R1 from falling after the fall on 5/21/25. An incident report dated 5/29/25 states, On 5/27/25 at approximately 6:40PM the resident was reported to have an unwitnessed fall in the resident's room when attempting to self transfer to the restroom. This same report states, On 5/28/25 the resident was noted to be complaining of mild-moderate pain to the right side. An X-ray was ordered and performed on 5/28/25. X-ray results showed acute appearing right lateral 8-11 rib fractures with displacement and mild soft tissue swelling. NP (Nurse Practitioner) updated with results and order was given to transfer resident to the ED (Emergency Department) for further evaluation and treatment. This report also states, The resident has a BIMS (Basic Interview for Mental Status) of 12 on 12/13/24 (mild cognitive impairment). At the time of the resident's fall, the resident stated he was attempting to walk to his bathroom .R1's Radiology Report dated 5/28/25 states, Acute appearing right rib fractures. R1's Hospital admission Report dated 5/28/25 states, He had a mechanical fall- tripped and fell- about 2 days ago. Hitting his right side chest. He was discovered to have 4 broken ribs 8-11. He was brought to the ED tonight for further evaluation. He is complaining of pain onto his lateral right chest and right back. He is having difficulty breathing .Upon arrival in the ED he was hypoxic at 89% on room air at rest. He was tachypneic. Blood pressure was borderline low. On 7/21/25 at 2:30PM V2 (Director of Nursing) stated, (R1) was more confused than normal on the 21st after his first fall. He was with it and could answer questions but something was just off. The (V6- Nurse Practitioner) ordered a UA (Urinalysis). I didn't talk to any of the family before that. We did the UA and we could have started antibiotics based on that but (V6) waited for the culture. The UA looked bad but some of the doctors wait for the culture- I think we should start the antibiotic and change it if we need to when the culture arrives. The UA was done to try to clear up some of the confusion to prevent falls. On the second fall on the 27th the granddaughter came in right after it and thought he was a little confused and I told her that is how he has been and then we sent him out the next day for the rib fractures. I remember he told me that some guys had come into his room and he had to chase them out and then he had to go to the parking lot to get his truck. V2 did not know of any other Page 1 of 2 145312 145312 07/21/2025 Symphony Northwoods 2250 Pearl Street Belvidere, IL 61008

F 0689 Level of Harm - Actual harm Residents Affected - Few interventions put in place after R1's first fall while they were waiting for the results of the UA. On 7/21/25 at 2:45PM V6 stated, If the resident is stable and there is no fever, chills, lethargy etc. then we wait for the culture. If the nurse would have told me there were other symptoms than confusion then I may have started the antibiotic before the culture. I could do a UA and start antibiotics on every resident up there just based on confusion. I like to wait for the culture so we are not giving antibiotics unnecessarily to all these elderly people.R1's Physician's Order Sheet for May 2025 shows that R1 has diagnoses including Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Difficulty Walking, Unsteadiness on Feet, Depression, History of Falling and Metabolic Encephalopathy. This form also shows that R1 was started on antibiotics for a Urinary Tract Infection on 5/25/25. R1's Fall Risk assessment dated [DATE] shows that he is a High Risk for Falls. 145312 Page 2 of 2