Health inspection·September 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 previously implemented fall intervention was in place to reduce the risk of a fall for one of three residents (R1) reviewed for falls in a sample of three. This failure resulted in R1 being transferred to the local area emergency room with a left forehead laceration, a left frontal scalp soft tissue hematoma, multiple skin tears and experiencing severe pain.Findings include: The facility's Fall Prevention Policy, dated 2/2025, documents Purpose: To provide as safe an environment as possible by taking measures to prevent falls to the extent possible. Policies: C. Every resident shall have safety measures included in the Care Plan from the time of admission. D. The Care Plan safety measures shall be revised as appropriate after a fall occurs and when deemed necessary by nursing. E. After every fall, the cause of the fall shall be determined if possible and measures taken to prevent a similar occurrence in the future. The Accident/Incident Policy, dated 3/2025, documents I. Definition: An incident is any unusual happening involving a resident or visitor. This includes falls with or without injury; injury with or without a fall.; behavior which involves danger or injury to self, another resident, employee, or visitors; wandering behavior that puts the resident or other residents in danger; any other happening not considered usual that may create a risk to resident, staff, visitor, or facility. L. Every accident/incident shall be investigated to attempt to determine cause. The nurse and the CNA (Certified Nursing Assistant) will complete an investigation for all falls. M. Following the investigation and with a probable cause of the fall is determined, recommendations to prevent a similar fall in the future shall be added to the care plan of the resident. The facility's Silent Bed Alarm Policy, dated 12/2024, documents I. Purpose: In conjunction with the fall management program, mobility monitors serve to alert the care giver that resident may need assistance. II. Policies: A. A silent bed alarm shall be used at the discretion of the admission nurse, charge nurse, clinical coordinator, Assistant Director of Nursing, or Director of Nursing after assessment of the resident indicates the resident is at risk for falls. B. A silent bed alarm consists of a box that is connected to the resident's call light system and a pressure sensitive pad that is placed on the mattress. G. It is important for the staff on the lanes to be aware of those residents with silent bed alarms and to respond to the call lights promptly. Resident safety is paramount to other duties. H. All silent bed alarms when triggered shall be interpreted as the resident communicating a need. Staff will make attempts to determine the need and provide assistance. I. It shall be the responsibility of each shift to make sure all silent bed alarms are properly connected and functioning. J. It will be the responsibility of the staff member placing the resident in bed or chair that the silent bed alarm is functioning properly by ensuring the green light is flashing and indicating the alarm is in use. III. Procedures: A. Determine the need for a silent bed alarm through fall risk evaluation. D. Check the proper function of the bed alarm by setting it off and observing that the call light turns on and the CNA's phone rings when Page 1 of 4 145436 145436 09/03/2025 Apostolic Christian Restmor 1500 Parkside Avenue Morton, IL 61550

F 0689 Level of Harm - Actual harm Residents Affected - Few the alarm is activated. R1's Face Sheet documents R1 admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Unspecified Dementia (moderate) with Anxiety, Chronic Kidney Disease (Stage 3), COPD (Chronic Obstructive Pulmonary Disease), Generalized Anxiety Disorder, Gastro-esophageal Reflux Disease, Hypertension, Personal History of Transient Ischemic Attack, and Age-Related Osteoporosis without current Pathological Fracture.R1's Fall Risk Assessment, dated 7/24/25, documents R1 is a high risk for falls. R1's current Care Plan documents Problem Start Date: 7/24/2023. Category: Falls. (R1) is at risk for falls related to impaired cognition and being impulsive and thinking that she is capable of doing more herself. Approach Start Date: 7/24/23: 1. Keep call light within reach. Instruct and encourage (R1) to use call light and wait for staff before getting out of bed or off toilet. 2. Keep most frequently used items and assistive devices within reach. 3. Ensure proper footwear is sworn before transfers- non-skin shoes, slippers, socks. 4. Keep room free of clutter. 5. Night light at night. 6. (Staff alerting bed alarm). Monitor for self-transfers and appropriate use of call light. Flowsheet: Fall Prevention. R1's Occurrence Report, dated 10/18/23 and signed by V4/RN (Registered Nurse), documents Description: (R1) found on the floor. Date/Time of Occurrence: Known, enter date/time: 10/18/23 at 3:30 AM. What was the resident trying to do when the fall occurred? Self-Transfer. Personal Alarm Ordered: yes. Resulted in: Laceration. Skin Tear. Taken to Hospital: Yes. Injury Site: Size: Approximately two-inch laceration at hairline left side of head. Skin tear left shoulder. Color: Bloody. Amount of Bleeding: Large. Body Part: head. Equipment: Bed alarm did not respond to (R1) getting out of bed. Care Plans: Equipment issue referred to Maintenance. New/Additional Fall Prevention Strategies Implemented: Other: Bed alarm replaced. What interventions or changes in routine were implemented by staff? Check bed alarm each shift. R1's Nurse Fall Investigation, dated 10/18/23 and signed by V4/RN, documents What happened: (R1) attempted to self-transfer. Where was the resident: In her room. Severity Level: Major Injury Laceration. Treatment: Sent to Emergency Department, attempted to stop the bleeding. Injury: Laceration to (R1's) head. After reviewing the investigation, what do you think was the cause: (R1) attempted to transfer-unable. Interventions: Replaced bed alarm due to not alarming. R1's Skin Integrity Events, dated 10/18/23 and signed by V4/RN, documents Description: Laceration left side of head at hairline. Type of Injury: Laceration. Location and Size of Skin Tear/Laceration: Approximately two-inch laceration. Depth of Skin Tear/Laceration: Moderate. Blood Loss- Note Amount and Control: Large Amount. Wound Edges: Irregular. Activity During Skin Tear/Laceration Occurrence: Fall. R1's Skin Integrity Events, dated 10/18/23 and signed by V4/RN documents R1 received a skin tear to the left shoulder related to the unwitnessed fall on 10/18/23. R1's Care Plan, dated 10/18/23, documents Problem Start Date: 7/24/2023. Category: Falls. (R1) is at risk for falls related to impaired cognition and being impulsive and thinking that she is capable of doing more herself. Approach Start Date: 10/18/23. 10/18/23 (R1) was found on the floor. Intervention bed alarm changed out as the pad was not working. R1's Census documents R1 had a hospital leave on 10/18/23 and didn't return to the facility from the local hospital until 10/23/25.R1's Medical Record did not include evidence of any other fall investigation with a root cause analysis (besides what was listed above) for R1's 10/18/23 fall. R1's Hospital Records, dated 10/18/23 documents Chief Complaint: Fall. Subjective: History of Present Illness: (R1) is a [AGE] year-old female patient sent to emergency room via Emergency Medical Services after unwitnessed fall. (R1) is from (local nursing home). Was found by nursing home staff on the floor next to her bed bleeding from her head with a large skin tear to her left shoulder and right arm. These same Hospital Records documented, Chest X-Ray, Bilateral Shoulder X-Rays, Left Elbow X- Rays, and Right-Hand X-Rays. Clinical History: Hypertensive former smoker with low blood pressure, altered mental status, and 145436 Page 2 of 4 145436 09/03/2025 Apostolic Christian Restmor 1500 Parkside Avenue Morton, IL 61550

F 0689 Level of Harm - Actual harm Residents Affected - Few lacerations of the left shoulder and right arm status post fall. Narrative: Brain and Cervical Spine CT (Computed Tomography) without Intravenous Contrast. Findings: Small left frontal scalp soft tissue hematoma with probable overlying bandaging. Remainder of the scalp soft tissues are unremarkable. R1's Skin Integrity Events-Skin Ulcer Documentation, dated 10/23/23, documents Description: Left forehead large open wound. Dimension of Ulcer: 4cm (centimeters) x 2.5cm. Depth- Through the top layer of skin. Character of Wound bed: Other: Red, has blood and dried blood superior to open wound. Describe, if necessary: Depended wound is oval in shape, it has large open area. Surrounding tissue: Intact. Describe if necessary: superior skin was elevated appears to be a hematoma. Does the resident complain of pain at the site? Yes-Moans when dressed. R1's Skin Integrity Events, dated 10/23/23, documents Description: Skin tear left shoulder. Type of Injury: Skin Tear. Location and Size of Skin Tear/Laceration: Left shoulder 4.5cm x 3.5cm. Activity During Skin Tear/Laceration Occurrence: Fall.R1's Skin Integrity Events, dated 10/23/23, documents Description: Lower left leg. Type of Injury: Skin Tear. Location and Size of Skin Tear/Laceration: Lower Left Leg 1.5cm x 0.5cm. Activity during Skin Tear/Laceration Occurrence: Fall. R1's Skin Integrity Events: dated 10/23/23, documents Description: Three Skin Tears on Right Forearm. Type of Injury: Skin Tear. Location and Size of Skin Tear/Laceration: Cluster of three skin tears on right forearm. Bottom tear is 1.2cm x 0.4cm next skin tear is 90 degrees on the outer forearm it measures 2.5cm x 0.2cm and the third tear is parallel from dependent wound. This skin tear measures 1.7cm x 0.4cm. These three wounds have scabs on them but were created during the fall. Activity During Skin Tear/Laceration Occurrence: Fall. On 9/2/25 at 2:00 PM V6/R1's Family Member stated, I received a call from a nurse the morning of 10/18/23 notifying me that (R1) had fallen out of bed and that (R1) had a deep laceration to her left forehead and multiple skin tears. The nurse told me the bed alarm wasn't working properly so they were not alerted when (R1) was getting up on her own. It was then decided (R1) needed to go to the ER (Emergency Room) due to (R1's) deep laceration to her forehead and some loss of consciousness. V6 also stated when he arrived at the hospital, R1 was crying and experiencing severe pain. On 9/3/25 at 10:42 AM V4/RN stated R1's (staff alerting) bed alarm remained green while R1 was on the floor, but the alarm had never gone off when R1 had tried to get up from bed or had fallen. When R1 was transferred back onto the bed, the bed alarm remained green and still wasn't functioning properly. The alarm did not activate when we were moving her on or off the silent bed alarm. When paramedics arrived and transferred R1 from the bed to the gurney, the alarm then went off. The alarm was malfunctioning. V4 stated, When we would check the bed alarms on each shift, we (staff) would just look to see if the alarm was green. That typically meant they were working. If the alarm turned red, then that meant it wasn't working. We (or at least I) did not test the alarms any other way to determine if they were working properly or not. (R1) had a bed alarm in place for a fall precaution. (R1) had a large laceration observed to her left forehead with a large amount of blood surrounding (R1) on the floor. I also noticed a skin tear to (R1's) left shoulder. I called (V7/RN Supervisor) to come assist with transferring (R1) back to her bed. I then called (V5/R1's Family Member) first with no answer so then I called (V6/R1's Family Member) to let them know about (R1's) condition. (V7) then called (V8/R1's Primary Physician) to report (R1's) condition. It was determined after speaking to (V6) and then (V8) to send R1 out to the hospital due to the head laceration and her being lethargic. I did not get a chance to see if (R1) had any other skin tears at that time or measure any of the areas caused from the fall. On 9/3/25 at 11:47AM V7/RN Supervisor stated, (R1) was on the floor, and was observed to have had quite a bit of bleeding from (R1's) forehead. The blood had clotted and had stopped bleeding but there was a lot of blood on the floor surrounding (R1's) head. (R1) was lethargic at the time, kind of sleepy. 145436 Page 3 of 4 145436 09/03/2025 Apostolic Christian Restmor 1500 Parkside Avenue Morton, IL 61550

F 0689 Level of Harm - Actual harm Residents Affected - Few I remember calling (V8/R1's Primary Physician) and letting them know what was going on and then getting (R1) sent out to the hospital. That was my focus because (R1) seemed injured. V7 also stated they (the facility) uses silent bed alarms for high-risk residents who fall to assist with fall prevention. On 9/2/25 at 2:01 PM V3/Director of Nursing stated any resident who is determined a high-risk fall, had fallen out of bed, or attempted to self-transfer would be placed on a silent bed alarm to help prevent falls, then the silent bed alarm would then be placed on the care plan for a fall intervention. V3 verified the only investigations from the fall the facility had was from V4/Registered Nurse who determined the root cause of the fall was the silent bed alarm had not been functioning properly when R1 got up, so staff were not alerted to get to R1 before R1 had fallen. V3 stated, The care plan intervention for (R1's) fall on 10/18/23 was to replace the malfunctioning bed alarm with a new alarm, so I am assuming the bed alarm was not functioning properly as it should. We (the facility) put in place around a year for staff to check the bed alarms each shift to ensure proper functioning, which include staff tapping on the bed alarm first to ensure the bed alarm beeps and is functioning properly prior to placing resident on the bed alarm. 145436 Page 4 of 4