Health inspection·May 20, 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 properly transfer and use appropriate assistive devices for transfers for 1 of 3 (R2) resident investigated for falls. This failure resulted in R2 sustaining a left knee periprosthetic fracture of the tibial component. Findings include: R2's EMR (Electronic Medical Record) undated documents that the resident was readmitted to the facility on [DATE]. R2's EMR dated 2/9/22 documents a diagnosis of other abnormalities of gait and mobility. R2's EMR dated 11/5/24 documents a diagnosis of difficulty in walking, not elsewhere classified. R2's EMR dated 8/14/24 documents a diagnosis of unspecified fracture of left fibula, subsequent encounter for closed fracture with routine healing. R2's MDS (Minimum Data Set) dated 7/26/24 documents a BIMS (Brief Interview for Mental Status) score of 15 out of 15. The MDS documents that the resident was independent for roll left and right. The MDS documents that the resident required substantial/maximal assistance for sit to lying. The MDS documents that the resident required partial/moderate assistance for lying to sitting on side of bed. The MDS documents that the resident was dependent for sit to stand, chair/bed to chair transfer, and toilet transfer. R2's Care Plan dated 4/30/25 documents (R2) is at risk for falls. She had a L knee replacement and is unstable ambulating and transferring herself. R2's Care Plan dated 4/30 /25 documents The resident has had an actual fall with serious injury. R2's Nursing Note dated 8/3/24 at 1:15 PM documents cna (Certified Nursing Assistant) came to this nurse to let this nurse know that resident was lowered to the ground. CNA stated resident stated that her left leg gave out and then she was lowered her to the ground. States her left knee hurts. ROM (Range of Motion) WNL (Within Normal Limits). Transferred back to wheelchair. V/S (Vital Signs)-97.2-102-22-102/64-spo2 (oxygen saturation)-97%. On call NP (Nurse Practitioner)-for (V6) notified. No number to contact for her husband. Will monitor. Tylenol given for pain. R2's Nursing Note dated 8/14/24 at 5:30 AM documents X-ray results of tib/fib back- results showed Page 1 of 2 145410 145410 05/20/2025 Evercare of Breese 1155 North First Street Breese, IL 62230

F 0689 fracture involving distal fibula. Management notified. X ray results were also taken on 8-4 of femur and tib/fib, results were negative on 8-4. Level of Harm - Actual harm Residents Affected - Few R2's NP Progress Note dated 10/8/24 documents Patient is being seen today for a skilled nursing home visit. She was recently admitted to the facility following hospitalization for UTI, debility and septic joint. She underwent arthrocentesis with orthopedic surgery and IV antibiotics during her hospital stay. She then fell in the facility and now has a left knee periprosthetic fracture of the tibial component. She is A&O x 3 and can verbalize her needs. She was seen today in-her room while sitting in her wheelchair. She has been released from her immobilizer and is WBAT to her LLE. Although, she now reports she reinjured her right knee by twisting while in the wheelchair. She states she doesn't have any pain but is unable to stand on it and now it is red again and swollen. She is utilizing the wheelchair for ambulation. Staff has no acute concerns at this time. On 5/20/25 at 9:15 AM, V4, PTA (Physical Therapy Assistant) stated that (R2) started off as (Mechanical) lift for transfers and then transitioned to a sit-to-stand for transfer when she got here in July of 2024. On 5/20/25 at 10:48 AM, V5, CNA stated that she was helping (R2) to the bathroom on 8/3/24. She stated that (R2) was a one assist with a gait belt. She stated that she was assisting (R2) to the bathroom. She stated that about the time they made to the doorway of the bathroom, that (R2's) leg gave out and was she assisted to the floor. She stated that they used a (Mechanical) lift to get her up off the floor. On 5/20/25 at 10:50 AM, V4, PTA stated that on the day of (R2's) fall, she was supposed to be transferred using a sit-to-stand device. On 5/20/25 at 12:32 PM, V4, PTA stated that the CNA transferring (R2) improperly lead to her having a fracture leg. She stated that the therapy was working with contact guard assist with (R2) but she was not released yet. Facility's policy undated documents It is policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. 1. The interdisciplinary team or designee will evaluate and assess each resident's individual mobility needs, taking into account other factors as well, such as weight and cognitive status. 2. The resident's mobility needs will be addressed on admission and reviewed quarterly, after a significant change in condition or based on direct care staff observations or recommendations. 145410 Page 2 of 2