Health inspection·September 25, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on interview and record review the facility failed to implement/update interventions following an accident/fall for two residents (R1, R3) of three residents reviewed for care plans in a sample list of three residents. Findings include: The facility's policy Fall Prevention revised 11/10/18 states Immediately after any resident fall the unit nurse will assess the resident and provide any care and treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. The unit nurse will place documentation of the circumstances of the fall in the nurse's notes or on an AIMS for wellness form along with any new interventions deemed to be appropriate at the time. 1. R1's Progress Note dated 8/25/2023 at 10:13PM documents CNA (V3, Certified Nurse's Aide) getting (R1) ready to transfer and was putting recliner down. (R1's) legs were in between recliner and where it closes, (V3) didn't notice (R1's) legs were hanging off due to blanket covering (R1's) legs. Resident stated 'Oww' and (V3) noted legs were hanging off sideways where recliner closes. (V3) moved blanket and noted resident right leg bleeding. (V3) notified Nurse (V7, Licensed Practical Nurse LPN). (V7) went in and assessed (R1's) right leg and large skin tear/laceration down front of right shin to almost (R1's) ankle. Bleeding profusely. Applied pressure and (abdominal gauze) with tape to area to try and stop bleeding. NP (Nurse Practitioner) notified at 9:06PM and gave order to Send to Emergency Room. Notified daughter 9:20PM. 911 called at 9:30PM. Director of Nursing /Administrator notified at 9:40PM. R1's Progress Note dated 8/25/2023 at 11:50PM and R1's Progress Note dated 9/12/2023 1:22PM go on to document (R1) received 13 sutures and (Nylon wound closure strips) at the emergency room to close the wound. R1's Care Plan printed 9/25/23 at 11:40AM does not document any resident centered interventions were initiated following this incident to prevent reoccurrence. 2. R3's Progress Note dated 8/23/2023 at 1:04PM documents: (R3) was ambulating with wife without a gait belt, wife was walking in front of him, leaving the dining room table. (R3) stated he blacked out. (R3) then fell back into the nurse's cart, knocked the water pitcher over, hit the trash can on the way down. (R3) moves all extremities, no rotation/shortening noted, complains of pain only back of head, (R3) has a knot on the back of the head left midline, (R3's) back is red. (mechanically lifted) resident to bed. Doctor notified. order to send out. emergency room called. Wife was here for Page 1 of 4 145466 145466 09/25/2023 Twin Lakes Extended Care 310 Eads Avenue Paris, IL 61944

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few incident, agreed to send to emergency room per Doctor request, Vital Signs 129/70 Blood Pressure, 97.7 Temperature, 99 Oxygen, 80% Pulse, 22 Respirations. Pupils Equal, Round, Reactive to Light and Accommodation. Resident on Eliquis (blood thinner). R1's Care Plan printed 9/25/23 at 12:33PM does not document any resident centered interventions were initiated following this incident to prevent reoccurrence. On 9/25/23 at 2:15PM V2, Director of Nursing stated We have been without a Care Plan Coordinator for a while and have had to depend on Corporate staff to do Care Plans. We are aware we have some issues but are currently training our new Care Pan Coordinator. 145466 Page 2 of 4 145466 09/25/2023 Twin Lakes Extended Care 310 Eads Avenue Paris, IL 61944

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 Based on interview and record review the facility failed to ensure one resident (R1) of three residents reviewed for accidents in a sample list of three was not entrapped in the mechanism of a recliner chair prior to lowering the footrest. This failure caused (R1) to sustain a 12 Centimeter laceration requiring 13 sutures to close. Findings include: R1's Diagnoses list printed 9/25/23 includes the following diagnoses: Age-Related Osteoporosis, Hypertension, Gastro-Esophageal Reflux Disease, Anxiety Disorder, Chronic Atrial Fibrillation, Repeated Falls, and Dementia. R1's Brief interview of Mental Status dated 6/29/23 documents R1 scored 3/15 on her Brief Interview of Mental Status indicating R1 is severely cognitively impaired. R1's Progress Note dated 8/25/2023 at 10:13PM documents CNA (V3, Certified Nurse's Aide) getting (R1) ready to transfer and was putting recliner down. (R1's) legs were in between recliner and where it closes, (V3) didn't notice (R1's) legs were hanging off due to blanket covering (R1's) legs. Resident stated 'Oww' and (V3) noted legs were hanging off sideways where recliner closes. (V3) moved blanket and noted resident right leg bleeding. (V3) notified Nurse (V7, Licensed Practical Nurse LPN). (V7) went in and assessed (R1's) right leg and large skin tear/laceration down front of right shin to almost (R1's) ankle. Bleeding profusely. Applied pressure and (abdominal gauze) with tape to area to try and stop bleeding. NP (Nurse Practitioner) notified at 9:06PM and gave order to Send to Emergency Room. Notified daughter 9:20PM. 911 called at 9:30PM. Director of Nursing /Administrator notified at 9:40PM. R1's Progress Note dated 8/25/2023 at 11:50PM documents Received report from emergency room nurse. (R1) received sutures in Right Lower Extremity and (nylon wound closure strips) applied over them. (R1) will need to return in 10-14 days to Emergency Department to have them removed. No immersing leg in water, sponge baths only. Family was notified and updated on condition as well. R1's Progress Note dated 9/12/2023 1:22PM documents New order received to remove sutures from right shin. 13 sutures were removed without difficulty. Steri Strips applied with (nonstick gauze) and wrapped with (stretch gauze) until fully healed. Will continue to monitor. New treatment order to change dressing daily to right shin until healed. Leave (nylon wound closure strips) in place until fall off on their own. Report any signs/symptoms of infection. On 9/25/23 at 12:53PM V3, CNA (Certified Nurse's Aide) stated. I was taking care of (R1) on 8/25/23 evening shift. (R1) put (R1's) call light on. I went in to get (R1) ready for the CNA's to transfer to bed. I was a Nursing Assistant then. I have since passed the test and have my certificate. (R1) had a blanket over her legs so I did not see her right leg was in the space between the chair and the footrest. I lowered the footrest. R1 screamed Owe. I put the footrest back up and (R1) was bleeding quite a bit. I got the nurse who came in right away. The nurse put pressure on the cut, and we sent (R1) to the hospital. (R1) came back with stitches and a bandage. On 9/25/23 at 1:00PM V6, Nurse Practitioner stated The laceration absolutely was caused by (R1) catching her leg in the recliner. The facility could have prevented this by taking off the blanket and 145466 Page 3 of 4 145466 09/25/2023 Twin Lakes Extended Care 310 Eads Avenue Paris, IL 61944

F 0689 making sure (R1's) leg was not caught. Level of Harm - Actual harm On 9/25/23 at 10:00AM V2 Director of Nursing stated, At the time (R1's) leg was injured by the recliner (V3) had taken her CNA classes and passed her test but was not yet on the registry. The blanket should have been removed and (V3) should have made sure (R1's) feet and legs were on the footrest before it was lowered. Residents Affected - Few On 9/25/23 at 2:00PM V1, Administrator stated the facility has no specific policy in regard to incidents (other than falls) which cause injury. 145466 Page 4 of 4