Health inspection·December 27, 2024

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 to transfer a resident with a gait belt for one (R1) of three residents reviewed for accident/incidents in a sample of three. This failure resulted in R1 falling and injuring her left wrist where she was transported to the hospital, X-Rays obtained, R1 was ordered a wrist splint to be worn, and follow up appointment with an Orthopedic doctor. Findings include: Facility Transfer-Manual Gait Belt and Mechanical Lifts, revised on 1/19/18, documents Use of gait belt for all physical assist transfers is mandatory. One person transfer requires a gait belt. Facility Handbook, dated 1/2023, documents Resident Injuries and Incidents- A common cause of resident injury is falling. Falls are often caused by leaving a resident unattended; leaving a resident in the bathroom without supervision; and failing to use gait belt when transferring or ambulating a resident. Facility Safety Belt Policy, dated 8/10/24 and signed by V5 CNA/Certified Nurse Aid documents All staff that assists residents with ambulation and/or transfers will use a safety belt as indicated to promote safety for the resident and staff. I have received a safety belt from the facility, and I have my own safety belt. V5 CNA/Certified Nurse Aid Employee File documents V5 was hired on 8/2/24. R1's Incident Report, dated 12/19/24, documents the following: (R1) was being toilet by the CNA (V5). (R1) described the CNA (V5) as hurrying to transfer which resident believes to have resulted in her fall. Complaints of pain to left arm. Change of plane from the toilet to the floor in her bathroom. The CNA (V5) tried to assist her off the toilet by her bra resulting in a change of plane from the toilet to the bathroom floor. (R1) pointed to her left arm when asked if any pain. (V8) Nurse and (V5) CNA assisted (R1) off the floor and into bed (no gait belt used). (V8) Nurse standing behind (R1) and (V5) CNA standing in front of (R1) helped (R1) off the floor and (R1) got into bed. Terminated (V5) CNA and DNR/do not return (V8) agency nurse due to improper transfer per facility policy while getting resident up off floor. Facility Daily Shift Assignment, dated 12/18/24, documents V5 CNA worked from 11PM on 12/18/24 until 7AM on 12/19/24. R1's current Care Plan with a date initiated on 4/18/24, documents I have an ADL/Activities of Daily Living self-care/mobility performance deficit that may fluctuate with activity throughout the day. This same Care Plan with a date initiated on 7/11/24, documents I am at risk for fall/injury Page 1 of 3 145413 145413 12/27/2024 Goldwater Care Toluca 101 East via Ghiglieri Toluca, IL 61369

F 0689 Level of Harm - Actual harm Residents Affected - Few related to wandering and poor safety awareness. CNAs/Certified Nurse Aids were re-educated on using appropriate transfer techniques transfer/manual gait belt and mechanical lift policy when assisting or transferring residents. R1's Minimum Data Set/MDS, dated 12/5/24, documents R1 is partial/moderate assistance for toilet transfer, and frequently incontinent of urine. R1's Nurses Note, dated 12/19/2024 at 4:45AM by V8 RN/Registered Nurse, documents Nurse standing at med cart at the nurses station preparing meds for morning med pass, heard loud crying from C wing (R1); Fax sent to MD/Medical Doctor to inform as well as ask if x-ray for right wrist was ok. R1's Pain Assessment, dated 12/19/24, documents Pain the left forearm, complained of pain in the left wrist, previous fracture, and received pain medication. R1's Progress Note, dated 12/16/2024 documents (R1) is a [AGE] year-old female presented to the OT/Occupation Therapy department due to (R1) recently had a cast from LUE (left upper extremity) wrist/forearm removed and returned from MD/Medical Doctor with orders to address left wrist ROM/Range of Motion and strengthening - no restrictions per MD note. R1's X-Ray, dated 12/19/2024, documents Acute comminuted, slightly dorsally impacted fracture of the distal radial epiphysis with resultant slight positive ulnar variance. R1's X-Ray, dated 12/21/24, documents History of left wrist fracture status post fall 12/19/24. Intra-articular distal radial fracture with re-demonstrated dorsal impaction. Acute chronic non-displaced fracture is difficult to exclude by imaging and clinical correlation is advised. R1's After Visit Summary, dated 12/21/24, documents R1 had a fall with an arm injury and diagnosed with left wrist pain; follow up appointment on January 13, 2025, at 8:30AM with an Orthopedic office; and instructions to Wear Velcro splint as tolerated. Continue with over-the-counter pain medication if needed. Follow up with Orthopedics for a recheck as needed. R1's medication record, dated 12/22/24, documents R1 was prescribed Tylenol 650 mg/milligrams by mouth every six hours as needed for pain. R1's Progress Note, dated 12/23/2024 by V6 APRN/Advanced Practice Registered Nurse, documents (R1) was seen on this day for a follow-up visit. (R1) has had a recent fall on 12/20/24, that resulted in Left wrist/forearm discomfort. (R1) had had a previous injury to her left wrist/forearm are that resulted in two fractures - previous x-ray results from 8/30/24 revealed a non-displaced fracture of the ulnar styloid and a comminuted intra-articular fracture of the distal radius. (R1) had a follow-up x-ray on 12/19/24 that had similar results to the x-ray completed in 8/2024 - this result includes a dorsally impacted, intra-articular fracture of the distal radius, and stated to have no comparison exam. The fracture was not stated to be new or healing. (R1) was sent to local ER/emergency room on [DATE] where an additional x-ray was completed. This x-ray revealed the intra-articular distal radial fracture that was stated to have re-demonstrated dorsal impaction. On 12/26/24 at 11:50AM, R4 (R1's roommate) was alert and oriented and stated (V5 CNA) toileted (R1) on 12/19/24. (R1) needs help wiping herself, she goes to the bathroom a lot about 2-3 times an hour, and the staff gets impatient. (V5) took her in the bathroom to toilet, she fell somehow with (V5), but I couldn't see everything because the bathroom door was partially closed but I could hear a commotion of voices in the bathroom, and now (R1's) arm is in a brace. (R1) said (V5) made her fall. 145413 Page 2 of 3 145413 12/27/2024 Goldwater Care Toluca 101 East via Ghiglieri Toluca, IL 61369

F 0689 Level of Harm - Actual harm Residents Affected - Few On 12/26/24 at 12PM, V7 LPN/Licensed Practical Nurse stated I worked midnights until December 2024. (R1) she needs assistance with toileting because she wears a pull up and needs assistance wiping her behind because her arms are too short. 12/26/24 at 12:10PM, V3 RN/MDS/Interpreter stated (R1) had a fracture of her left arm a few months back. On 12/19/24 (R1) stated (V5 CNA) toileted her, (V5) grabbed her bra in the front of her that she was wearing to help her off the toilet and she fell on her hands and knees and hurt her left wrist. (V5) left the room after (R1) screamed and went to get the nurse. On 12/26/24 at 12:15PM, R1 was interviewed through V3 RN (Registered Nurse)/MDS (Minimum Data Set)/Translator due to R1 Spanish speaking only. At that time, R1 confirmed the following: she fell when in the bathroom with V5 CNA when V5 CNA assisted R1 off the toilet by her bra and R1 lost her balance and went down on the bathroom floor on her hands and knees; R1 needs assistance with toileting and wiping herself; V5 CNA did not use a gait belt to get her on/off the toilet; and V5 CNA and V8 RN/Registered Nurse did not use a gait belt to get her off the floor. At that same time, R1 was observed wearing a brace to her left wrist and stated her left wrist hurts. On 12/26/24 at 12:45PM, V1 Administrator stated (V5 CNA) was terminated and the agency nurse was DNR due to not following our transfer policy (on 12/19/24). When asked if due to no gait belt used V1 nodded and stated Yes they did not use a gait belt to get (R1) off the floor and that is our policy for transfers. (V5) was trying to get (R1) dressed for the day and (V5) transferred her off the toilet. (V8) had already heard (R1) scream and start crying and saw (V5) come out the adjoining bathroom door. (R1) had fallen and broke her left wrist prior. Her wrist was healing, and she was not wearing the brace anymore. (R1) came to the nursing home in September 2024. 145413 Page 3 of 3