Health inspection·January 10, 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 observation, interview, and record review the facility failed to a.) provide appropriate supervision b.) reduce the risk of a fall for one (R5) resident out of five residents reviewed for falls, in a total sample of five residents. This failure resulted in R5 sustaining a fall without injury. Findings include: On 01/08/2025, at 11:45 AM, V6 (Certified Nursing Assistant) states that she is working the middle set assignment. Surveyor asked V6 which residents on her set are high fall risk. V6 states that R5 fell this morning. V6 continues that she was barely arriving to work when the night shift nurse found R5 on the floor, his bottom on the floor, in his room, next to his bed. 01/08/2025, 11:50 AM, R5 in bed lying down and in no apparent distress. R5 wearing white socks but not non-skid socks. R5's bed is not at the lowest position. Urinal noted approximately 5 feet away from R5's bed on the floor, sideways, no urine inside the urinal noted. Black shoes noted near R5's nightstand, next to R5's bed. Surveyor asked R5 what his full name is, R5 answered correctly. Surveyor asked R5 if he knows where he is at, R5 states the name of the facility. R5 was asked who the president is and R5 answered correctly. R5 was asked when Christmas is, and R5 answered 25th, but could not recall the month. R5 states that he did fall this morning. R5 states that he lost track of how many times he has fallen. R5 states that he cannot blame the staff entirely. R5 states that he needs some assistance with putting on his shoes. R5 states that sometimes he can get one shoe and not the other. 01/08/2025, 12:07 PM, R5's room door open, R5 sitting at edge of bed, attempting to stand, noted unbalanced, with no nonskid socks on. Surveyor informed V7 (Registered Nurse) and V7 went into R5's room to assist him. R5 sat down on his bed. V7 brought a spoon to R5. 01/08/2025, 12:09 PM, V7 states that R5 just wants to get up despite being weak and does not use the call light to call for assistance. V7 states that R5 forgets a lot. V7 states that R5's wheelchair is outside of R5's room because it is too tight for R5's roommate to get through. V7 states that R5's keeps forgetting to call for help. V7 reports that R5 has the urinal and bed commode, but he also forgets to use them. V7 continues to state we ask him (R5) why he didn't call, he says he forgot. He doesn't like to stay in the bed or wheelchair for too long. On 01/09/2025, at 2:48 PM, V17 (Licensed Practical Nurse) states that she was the night shift nurse for R5 on Tuesday night. V17 states that it was around 7:37 AM when R5's roommate approached V17 to inform her that R5 needed help. V17 states that she went to R5's room and R5 was at the edge of the Page 1 of 2 145343 145343 01/10/2025 Ambassador Nursing & Rehab Center 4900 North Bernard Chicago, IL 60625

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bed, and she told him to wait. V17 states I personally couldn't transfer him to the wheelchair by myself, so I told him to wait. V17 continues she went out to get the CNA (Certified Nursing Assistant). V17 states that she got the help of the CNA. V17 states that R5's bed was at the lowest position and R5's back was on the edge of his bed. V17 states that V7 (Registered Nurse) was coming from the elevator. V17 reports that V7 also helped transfer R5 to the wheelchair. V17 reports that R5's bottom was on the floor, but his back was on the bed. V17 states that she didn't think it was a fall at that time. V17 states that it could be considered a fall though. On 01/09/2025, at 1:25 PM, V2 (Director of Nursing) states that she checked with the facility consultant and there are no other fall policies. 01/10/2025, 1:36 PM, V2 states that she agrees R5 should have had non-skid socks on. R5's current face sheet documents R5 is a [AGE] year-old individual admitted to the facility on [DATE]and has diagnoses not limited to: unsteadiness on feet, unspecified lack of coordination, repeated falls, weakness, need for assistance with personal care, dry eye syndrome of bilateral lacrimal glands, major depressive disorder, single episode, unspecified. R5's MDS/Minimum Data Set, dated [DATE], documents that R5 has a BIMS/Brief Interview for Mental Status score of 13/15, indicating that R5 is cognitive intact. R5's MDS section GG Functional Abilities dated 12/24/2024, documents in part that R5 requires partial/moderate assistance to put on/take off footwear. R5's fall risk review dated 12/27/2024, documents in part that R5 is a high risk for falls. R5's current risk for falls care plan documents in part, R5 will have a safe environment maintained through next review. Ensure that I'm wearing appropriate footwear that provide stability and good traction when ambulating. Bed will be on lowest position while in bed. R2 would like staff to provide me with a safe environment with floors free from spills and/or clutter, adequate glare-free lighting, a working and reachable call light, and bed mobility positioning devices and transfer devices as applicable to support my highest level of bed mobility and transfer independence. Facility document not dated, titled Incidents/accidents/falls documents in part, the resident's care plan will be addressed to ensure that any needed points to focus have measurable goals with appropriate interventions in place. 145343 Page 2 of 2