Health inspection·April 3, 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 ensure a resident was rolled in a safe manner by two staff persons during incontinence care for 1 of 3 residents (R1) in the sample of 3 reviewed for safety and supervision. This failure resulted in R1 falling out of bed and sustaining fractures of her right and left femurs. The findings include: R1's Face Sheet dated 4/2/25 shows R1 was admitted to the facility on [DATE] with a diagnosis of osteitis deformans of other bones (chronic condition affecting bone structure). R1's MDS dated [DATE] shows R1 requires substantial/maximal assistance to roll left and right (the ability to roll from lying on back to left and right side and return to lying on back on the bed) and with toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement). This same MDS also shows R1 is always incontinent of bowel and bladder. R1's Clinical Notes dated 3/13/25 at 6:58 AM show the following excerpt, While providing incontinence care, CNA stated she turned resident on her side when her legs then dangled off the bed and caused her to slide off the bed. CNA then did her best to lower resident to the floor. On 4/2/25 at 9:10 AM, R1 was lying in bed on an air mattress. R1 said she broke both of her legs a couple weeks ago after she fell out of her bed. R1 said all she knows is that a lady was on one side, and she was on the other side and, I got dropped. R1 said only one person was with her. On 4/2/25 at 2:45 PM, V7, Certified Nursing Assistant (CNA) said she had been changing R1 by herself (on 3/13/25) and as she was rolling R1 in bed, she moved a little too hard, and R1's feet started to slide off the bed. V7 said R1's legs are dead weight and the weight of her body was pulling her off the bed. V7 said R1's legs are so heavy, the (air) mattress is slippery and R1 has no control over her legs, so R1 started to slide out of the bed. V7 said she was unable to get R1's legs back into the bed so she guided her head and shoulders as R1 fell out of her bed. V7 said it all happened so fast she is not sure if R1's knees hit the floor when she fell out of her bed. On 4/2/25 at 9:29 AM, V10, CNA, said before R1 fell, she required two people to change her, one on each side of the bed. On 4/2/25 at 9:39 AM, V9, CNA, said R1 required two people to change her. V9 said for bed baths, one person could wash R1's front side, but then they would need to get a second person to come help turn R1 and wash her back side. (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 2 Event ID: 145409 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 145409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Michaelsen Health Center 831 North Batavia Avenue Batavia, IL 60510 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)